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http://www.archive.org/details/surgerypathologyOOochs 


SURGERY  AND  PATHOLOGY 


OF  THE 


THYROID  AND  PARATHYROID  GLANDS 


.J!  , 


THE 


SURGERY  AND  PATHOLOGY 


OF  THE 


Thyroid  and  Parathyroid  Glands 


BY 

ALBERT  J.  OCHSNKR,  A.  M.,  M.  D.,  LL.  D.. 

Professor  of  Surgery  in  the  Medical  Department  of  the  University  of  Illinois, 
Chief  Surgeon  to  Augustana  Hospital  and  St.  Mary's  Hospital,  Chicago, 

and  •; 

RALPH  L.  THOMPSON,  A.  M.,  M.  D., 

Professor  of  Pathology  in  the  St.  Louis  University  School  of  Medicine, 

St.  Louis. 


ft 
With  57  Illustrations  in  the  Text  and  40  Full-1/a.ge  Plates, 
4  of  the  Plates  being  in  Colors.    , 


ST.  LOUIS,: 
C.  V.   MOSBY  COMPANY, 

19 10  J|t  i 

I    ■  I 


Copyright,  1910,  by  C.  V.  Mosby "Company, 


£  &} 


I   ' 


TO 

DR.  CHARLES  H.  MAYO, 

IN    RECOGNITION    OF    HIS    SPLENDID  WORK   IN   THE 
DEVELOPMENT  OF  THYROID    SURGERY  IN  AMERICA, 

THIS   VOLUME   IS   DEDICATED   BY 

THE  AUTHORS. 


PREFACE. 

The  great  interest  that  surgeons  and  pathologists 
are  experiencing  in  the  study  and  treatment  of 
diseases  of  the  thyroid  and  parathyroid  glands 
seems  to  justify  the  production  of  the  present 
volume,  which  has  been  planned  to  bring  to  the 
practitioner  of  surgery  and  medicine  the  result  of  a 
study  of  the  work  of  those  who  have  given  much 
time  to  the  development  of  this  special  field.  It 
also  includes  the  clinical  and  technical  personal  ex- 
perience in  the  surgical  treatment  of  a  large  number 
of  patients  suffering  from  diseases  of  the  thyroid 
gland  which  have  come  under  the  care  of  the  senior 
author  during  the  past  twenty  years.  It  has  seemed 
proper  to  give  special  emphasis  to  details  which 
have  practical  value  in  the  diagnosis  and  treatment 
of  exophthalmic  goitre,  because  in  this  matter  this 
book  will  probably  have  its  greatest  field  of  use- 
fulness. 

In  the  chapter  on  thyroid  pathology  the  attempt 
has  been  made  to  simplify  as  much  as  possible  our 
understanding  of  goitre.  A  basis  for  a  clinical  and 
pathological  correlation  of  the  symptoms  and  mor- 
phological changes  in  the  thyroid  gland  in  exoph- 
thalmic goitre  has  been  offered  by  Dr.  Louis  B. 
Wilson',  and  we  have  taken  full  advantage  of  his 
excellent  study  of  the  subject.  We  are  also  in- 
debted to  Dr.  Wilson  for  several  illustrations  which 
accompany  the  text.  The  organization  of  surgical 
clinics  has  made  possible,  by  the  proper  relationship 
of  surgeon,  internist  and  pathologist,  not  only  the 


6  PREFACE 

most  satisfactory  treatment,  but  also  the  most 
advanced  pathological  study  of  this  disease  that  we 
are  able  to  offer  at  the  present  time. 

An  apology  for  the  compilation  of  the  main  facts 
regarding  the  parathyroid  glandules  here  presented 
is  not  necessary.  These  vital  organs  have  been  too 
long  neglected,  both  in  medical  text  books  and  in 
medical  teaching.  Most  students  have  never  seen 
the  parathyroid  glandules,  and  there  is  no  text  book 
that  devotes  more  than  a  brief  paragraph  to  these 
bodies — organs  that  are  necessary  for  the  mainte- 
nance of  life.  In  fact,  until  the  excellent  chapters  of 
Dr.  George  Dock  appeared  in  Osier's  Modern  Medi- 
cine even  the  more  exhaustive  books  had  practically 
disregarded  these  glandules. 

The  author  of  this  section  of  the  book  wishes  to 
express  his  indebtedness  to  Professor  Ludwig  Pick, 
Director  of  the  Pathological  Institute,  Friedrichs- 
hain,  Berlin,  for  assistance  and  stimulation  which 
has  led  to  the  accomplishment  of  much  of  the 
original  work  by  the  author  that  is  included  in 
these  chapters. 

The  section  of  the  book  on  the  thyroid  gland,  with 
the  exception  of  the  chapter  on  pathology,  is  written 
by  the  senior  author ;  this  chapter  and  the  section  on 
the  parathyroid  glandules  are  by  the  junior  author. 

A.  J.  Ochsner. 
R.  L.  Thompson. 


CONTENTS. 


PART  I. 


Chapter • 

I. 

Chapter 

II. 

Chapter 

III. 

Chapter 

IV. 

Chapter 

V. 

Chapter 

VI. 

Chapter 

VII, 

Chapter 

VIII. 

Chapter 

IX, 

Chapter 

X. 

Chapter 

XI 

THE  THYROID  GLAND. 

The    Surgical  Consideration   of  the   Thyroid 

Gland ' 9 

The  Pathology  of  the  Thyroid  Gland     ...  14 

Diagnosis 36 

Non-Surgical    Treatment 77 

Anaesthesia 90 

Dangers  of  Operation 110 

Indications    for    Operation    on    the  Thyroid 

Gland 119 

Thyroidectomy 126 

Other  Operations  on  the  Thyroid  Gland     .     .  163 

Prognosis  in  Exophthalmic  Goitre     ....  178 

Heredity  in  Goitre     .........  191 


PART  II. 


THE  PARATHYROID  GLANDULES. 

Chapter       XII.     Introduction — Historical — Function       .      .     .  199 

Chapter     XIII.     Anatomy 209 

Chapter     XIV.     Embryology  and  Histology 227 

Chapter       XV.     The  Pathologic  Histology  of  the  Parathyroid 

Glands 243 

Chapter      XVI.     Cysts  and  Tumors 268 

Chapter    XVII.     Relation  of  the  Parathyroid  Glands  to  Post- 
operative Tetany 281 

Chapter  XVIII.     Surgical    Accidents  in  Man  Due  to  Removal 

of  the  Parathyroid  Glandules 311 

Chapter     XIX.     The    Relation   of  the   Parathyroid  Glands  to 

Medical    Tetany .  318 

Chapter       XX.     Parathyroid    Therapy 334 


PART  I. 


CHAPTER  I. 


THE    SURGICAL    CONSIDERATION    OF    THE 
THYROID    GLAND. 


INTRODUCTION. 

The  first  decade  of  the  present  century  has  added 
the  treatment  of  the  diseases  of  the  thyroid  gland 
to  the  surgical  side  of  our  art.  This  applies  more 
especially  to  that  form  of  disease  which  had  been 
most  discouraging  heretofore,  and  which  now  is  one 
of  the  most  satisfactory  conditions  in  the  field  of 
major  surgery — namely,  the  disease  generally  known 
in  America  as  exophthalmic  goitre. 

•  Although  the  diagnosis  is  practically  never  diffi- 
cult at  the  time  at  which  these  patients  come  into 
the  care  of  the  surgeon,  still  it  has  seemed  to  be  of 
great  importance  to  discuss  extensively  the  diagnosis 
and  differential  diagnosis,  and  with  this  the  history, 
etiology,  symptomatology  and  physical  findings. 

The  treatment,  after-treatment  and  prognosis  will 
be  considered  in  detail,  and  special  care  will  be  taken 
in  making  clear  the  points  in  the  technic  that  seem 
of  importance  in  making  the  operative  treatment 
safe  and  the  results  immediately  and  ultimately 
successful. 


10  THYROID   GLAND 

In  the  search  for  support  for  the  various  ideas  in- 
corporated in  this  volume  in  the  literature  of  the 
subject  there  have  been  encountered  in  the  original 
and  in  abstracts  and  references  nearly  twelve  hundred 
monographs,  articles  and  case  reports,  less  than  ten 
per  cent,  of  these  being  surgical. 

It  would  be  quite  useless  to  enumerate  these  and 

many  others  which  a  further  search  of  the  literature 

would  reveal,  and  consequently  only  those  have  been 

added  to  the  bibliography   that   have   aided  very 

materially  in  the  development  of  the   surgical   side 

of  the  subject. 

history. 

The  surgical  history  of  the  diseases  of  the  thyroid 
gland  is  extremely  meager  before  the  last  quarter 
of  the  past  century,  when  the  remarkable  work  of 
Theodor  Kocher  attracted  the  attention  of  the  entire 
surgical  world  by  his  practical  demonstration — first 
in  a  few,  then  in  hundreds  and  later  in  thousands  of 
cases — that  thyroidectomy,  if  performed  skillfully,  is 
not  the  extremely  dangerous  operation  that  the 
earlier  surgeons  had  pictured. 

He  eliminated  the  principal  dangers — namely,  those 
from  anaesthesia,  sepsis,  hemorrhage,  shock,  hyper- 
thyroidism, cachexia  strumipriva,  injury  to  the  re- 
current laryngeal  nerve  and  injury  to  the  para- 
thyroid glands- — and  gave  us  relatively  an  exceedingly 
safe  surgical  procedure.  In  many  of  these  features, 
and  especially  in  many  of  the  details,  much  impor- 
tant support  came  from  other  sources. 

Moebius  supplied  a  most  important  element  for 
the  rational  surgical  treatment  of  the  important 
class  of  exophthalmic  goitre  by  his  logical  and  con- 


HISTORY  11 

vincing  studies,  which  made  it  clear  that  in  this  dis- 
ease there  is  absorption  of  an  excessive  amount  of 
substance  secreted  by  a  diseased  gland,  which  enters 
the  general  circulation  through  the  lymphatic  system. 

This  important  element  will  be  referred  to  at 
length  at  the  proper  place.  In  connection  with  this 
part  of  the  history  of  this  subject  it  is  proper  to 
state  that  Rehn  pointed  out  just  a  quarter  of  a 
century  ago  the  splendid  effect  of  surgical  treat- 
ment on  exophthalmic  goitre,  and  Tillaux  had 
pointed  out  similar  results  four  years  earlier  in  the 
year  1880,  although  he  had  no  definite  theory  by 
which  he  could  explain  the  great  benefit  obtained 
by  excision  of  the  gland.  There  can  be  no  doubt, 
however,  that  the  surgical  treatment  of  exoph- 
thalmic goitre  resulted  directly  from  the  surgical 
work  of  Kocher  in  simple  goitre  and  the  pathological 
and  physiological  explanation  of  Moebius. 

In  this  as  in  most  other  instances,  the  benefit  of 
operative  treatment  of  exophthalmic  goitre  was 
first  observed  accidentally  in  cases  in  which  the 
goitre  was  removed,  not  to  cure  this  disease,  but  to 
relieve  pressure  or  deformity. 

To  the  development  of  the  technic  much  has  been 
added  by  the  work  of  Dr.  C.  H.  Mayo,  of  this  country, 
who  has  the  largest  personal  experience  in  the  treat- 
ment of  exophthalmic  goitre  at  the  present  time. 

The  subject  of  exophthalmic  goitre  in  its  clinical 
aspect  dates  back  much  further  than  the  entire  sub- 
ject does  in  the  surgical  aspect.  As  early  as  1786, 
more  than  one  and  a  quarter  centuries  ago,  Parry 
described  this  disease  clearly,  and  in  the  year  1800 
an    Italian  physician  of  the    name   of   Flajani   de- 


12  THYROID    GLAND 

scribed  a  disease  much  less  clearly  which  undoubted- 
ly represented  the  same  condition.  In  the  year  1828 
Adelmann  directed  attention  to  the  goitre  heart. 

In  the  year  1835  Graves  described  this  disease  in 
his  lectures,  which  were  published  in  book  form 
eight  years  later — hence  the  name  of  Graves'  disease. 
This  description  was  so  clear  that  it  was  accepted  as 
typical  by  English  speaking  physicians  throughout 
the  world. 

In  1840  v.  Basedow  described  this  disease  in  Ger- 
many, and  since  then  it  has  been  known  as  morbus 
Basedowii,  although  the  term  was  not  formally 
adopted  until  1858,  following  the  suggestion  of 
Hirsch. 

From  the  standpoint  of  symptomatology  and 
diagnosis  the  observations  of  Charcot  in  1856,  those 
of  v.  Graefe  in  1864,  those  of  Stellwag  in  1865,  those 
of  Marie,  beginning  in  1856  and  continuing  for  a 
period  of  forty  years,  seem  to  be  of  special  impor- 
tance, and  will  be  considered  fully  in  the  discussion 
of  that  portion  of  our  subject.  In  1873  Gull  de- 
scribed myxcedema.  In  1882  Kocher  established  the 
fact  that  this  condition  can  be  brought  about  regu- 
larly by  removing  the  entire  thyroid  gland — hence 
his  introduction  of  the  term  cachexia  strumipriva. 
The  most  important  historical  data  regarding  this 
portion  of  our  subject,  however,  seems  to  be  that 
Moebius  was  able  in  1886  to  permanently  establish 
the  fact  that  exophthalmic  goitre  is  a  "form  of 
poisoning  of  the  body  through  a  diseased  activity  of 
the  thyroid  gland,"  and  not  a  disease  due  to  some 
primary  lesion  of  the  central  nervous  system,  es- 
pecially the    medulla    oblongata;    neither  a  disease 


HISTORY  13 

due  to  a  pathological  condition  of  the  sympathetic 
nervous  system,  nor  a  form  of  hysteria.  It  is  a  disease 
due  to  a  pathological  development  in  the  thyroid 
gland  itself.  From  the  surgical  standpoint  the  cor- 
rectness of  this  theory  had  already  been  proven  by 
the  cure  of  many  patients  suffering  from  this  disease 
whenever  the  diseased  gland  has  been  removed. 
There  are  two  publications,  one  published  in  France 
by  Tillaux  in  1880  and  the  other  in  Germany  by 
Rehn  in  1884,  which  seem  of  specially  great  his- 
torical interest.  The  establishment  of  technic  which 
ensures  safe  and  permanent  surgical  treatment 
belongs  to  our  contemporary  surgeons. 


CHAPTER  II. 


THE  PATHOLOGY  OF  THE  THYROID  GLAND 


The  function  of  the  thyroid  gland  is  to  furnish 
an  internal  secretion,  which  is  not  only  important, 
but  indispensable,  for  the  building  up  and  mainte- 
nance of  the  organism.  A  lack  of  this  material 
leads  to  nutritional  disturbances  (myxcedema  or 
cachexia),  and  its  overproduction  to  nervous  phe- 
nomena (exophthalmic  goitre) .  Therefore,  in  a  study 
of  this  organ  we  are  most  interested  in  the  condi- 
tions which  give  rise  to  a  diminution,  an  increase, 
or  a  perversion  of  this  important  function. 

A  new  field  for  study  was  offered  in  the  experi- 
mental problems  that  suggested  themselves  in  con- 
nection with  thyroid  function,  which  was  opened  by 
the  discovery  of  Kocher  and  of  Reverdin,  that  ex- 
tirpation of  the  thyroid  was  followed  by  severe 
cachexia.  At  first  these  experiments  were  compli- 
cated by  a  lack  of  knowledge  of  the  parathyroid 
glands,  but  that  subject  has  now  been  made  clear 
by  a  more  exact  study  of  the  latter  organs,  which 
will  be  discussed  in  other  chapters.  Then  came  the 
observation  of  the  efficacy  of  mouth  administered 
thyroid  extracts  as  a  substitute  for  the  gland  itself, 
and  then  the  discovery  that  the  thyroid  possessed  a 
marked  power  of  regeneration  when  transplanted — 
sufficient,  indeed,  to  act  permanently  for  a  removed  or 
diseased  organ. 


< 

Oh 


THE  PATHOLOGY  OF  THE  THYROID  GLAND    15 

Our  knowledge  of  hyperthyroidism  has  been  in- 
creased by  the  ability  to  study  glands  removed  at 
various  stages  of  Graves'  disease,  but  the  compli- 
cated phenomena  that  occur  in  connection  with  the 
reaction  of  thyroid  diseases  on  the  organism  as  a 
whole  still  offer  a  rich  field  for  investigation  that 
may  well  lead  us  into  a  consideration,  not  only  of 
cretinism  and  exophthalmic  goitre,  but  also  of  such 
conditions  as  certain  neuroses,  psychoses  and  der- 
matoses, rickets  and  osteomalacia,  obesity,  and  allied 
conditions. 

Anatomy.  The  thyroid  gland  consists  of  two 
lateral  lobes,  connected  by  a  narrow  strip  called  the 
isthmus.  Each  lateral  lobe  is  somewhat  pyramidal 
in  form,  and  possesses  an  antero-external,  inner  and 
posterior  surface.  These  surfaces  come  together, 
forming  the  apex,  over  the  upper  posterior  part  of 
the  body.  The  lower  end  of  the  lateral  lobe  is  thick 
and  rounded.  The  isthmus  usually  crosses  the  second 
and  third  rings  of  the  trachea.  It  varies  in  size,  and 
is  sometimes  absent.  A  projection  may  extend  up 
from  either  the  isthmus  or  one  of  the  lateral  lobes, 
which  is  known  as  the  pyramidal  process  of  the 
gland.  The  inner  surface  of  the  lateral  lobes  lies 
against  the  trachea,  the  cricoid  cartilage  and  the 
lower  part  of  the  thyroid  cartilage,  and  reaches 
back  to  the  oesophagus. 

Considerable  variation  is  found  in  the  gross  blood 
supply  of  the  thyroid  gland.  In  general,  however, 
we  find  the  superior  thyroid  artery  approaching  the 
gland  at  the  upper  pole,  and  the  inferior  thyroid 
artery  approaching  from  beneath  the  gland.  These 
main   arteries    (superior   and   inferior  thyroid)    run 


16 


THYROID    GLAND 


along  the  margin  of  the  gland  and  form  anastomoses, 
which  vary  considerably  m  different  thyroids  (as  has 
been  described  in  detail  by  Landstrom).  Branch- 
ing of  the  large  arteries  is  mostly  upon  the  surface 
of  the  gland;  only  smaller  branches  penetrate  the 
tissue.  Small  arteries  pass  between  the  lobules,  and 
give  off  branches  which  supply  the  lobule;  these,  in 
turn,  divide  to  supply  the  individual  follicles.  The 
follicular  arteries  end  in  a  capillary  network.     The 


Fig.  1.  Scheme  showing  the  origin  of  the  different  branchial 
epithelial  bodies.  1,  2,  3,  4,  5,  branchial  grooves,  a,  median  thyroid, 
b,  lateral  thyroids,  c,  thymus,  dl,  outer  parathyroids.  6.2,  inner 
parathyroids.  5,  rudimentary  parathyroid  of  Getzowa.  (Modified 
from  Aschoff.) 

veins  follow  the  same  course  as  the  arteries  to  the 
surface  of  the  gland.  They  are  rich  in  anastomoses. 
The  lymph  spaces  in  the  thyroid  are  found  out- 
side the  capillary  network  which  surrounds  each 
follicle.  They  connect  with  larger  trunks  which  run 
between  the  lobules  into  still  larger  ones  between 
the  lobes,  and,  following  the  course  of  the  blood 
vessels,    finally    form  a     rich    lymphatic    network 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         17 

beneath  the  capsule  of  the  gland.  The  further 
lymphatic  drainage  is  usually  described  as  following 
out  the  blood  vessels,  one  trunk  passing  upward  and 
the  other  passing  downward. 

The  thyroid  gland  arises  from  a  median  unpaired 
evagination  of  the  epithelium  of  the  front  wall  of 
the  throat  in  the  vicinity  of  the  second  visceral  arch. 
This  detaches  itself  from  its  place  of  origin  and 
wanders  down  the  neck,  to  merge  finally  with  the 
second  points  of  origin,  which  are  from  the  epithelium 
of  the  fourth  visceral  cleft,  and  which  wander  up- 
ward somewhat  and  form  a  portion  of  the  lateral 
thyroid  bodies. 

At  first  the  proliferating  cell  masses  form  a  net- 
work of  solid  cords,  which  later  become  separated 
into  round  masses,  with  a  lumen.  The  cells  arrange 
themselves  as  a  lining  to  the  lumen,  which  finally 
becomes  somewhat  enlarged  and,  through  secretion 
of  the  cells,  filled  with  colloid.  These  mature,  rounded, 
closed  spaces  are  called  follicles.  In  the  adult 
thyroid  the  epithelial  cells  lining  the  follicles  may 
be  columnar,  cuboidal,  or  flat.  The  colloid  varies  in 
amount  and  staining  reaction,  as  will  be  described 
later  on.  The  follicles  are  surrounded  by  connective 
tissue,  carrying  blood  and  lymphatic  vessels,  as  has 
been  described.  The  capsule,  as  well  as  the  lobular 
partitions  of  the  gland,  is  made  up  of  dense  con- 
nective tissue. 

Between  the  follicles,  especially  in  the  new  born, 
one  finds  frequently  rests  of  foetal  tissue,  appearing 
in  strands  and  small  masses.  It  is  from  these  cells 
that  the  so-called  foetal  adenoma  are  supposed  to 
arise, 


18  THYROID    GLAND 

Abnormalities  of  Development.  Either  a  part  of 
the  thyroid  or  the  whole  gland  may  be  lacking. 
The  pyramid  or  the  isthmus  not  infrequently  pre- 
sents unusual  forms,  or  there  may  be  complete  lack 
of  development  of  these  parts,  as  well  as  absence  of 
one  of  the  lateral  lobes.  Aplasia,  or  complete  ab- 
sence of  the  thyroid  gland,  gives  rise  to  sporadic 
cretinism  or  congenital  myxcedema,  in  contradis- 
tinction to  the  endemic  variety  found  in  certain  re- 
gions, in  which  the  gland,  present  at  birth,  later 
undergoes  atrophy. 

Accessory  thyroid  nodules  are  frequently  found, 
sometimes  lateral  to  the  thyroid,  but  more  commonly 
in  the  neighborhood  of  the  hyoid  bone,  or  they  may 
be  below  the  gland  as  far  down  as  the  aortic  arch, 
behind  the  sternum.  Rarely  they  are  found  within 
the  larynx  or  trachea.  The  accessory  thyroids  are 
of  the  same  histologic  structure  as  the  thyroid  gland 
itself;  goitre  and  tumors  may  develop  from  them, 
just  as  from  the  main  gland. 

Failure  of  closure  of  the  thyroglossal  duct  may 
give  rise  to  cysts,  fistulae  or  tumor  formation. 

Circulatory  Disturbances.  The  thyroid  gland  has 
an  extremely  rich  blood  supply — so  rich,  in  fact, 
that  when  its  vessels  are  overfilled  (hyperemia)  the 
gland  may  be  notably  increased  in  size.  This  great 
development  of  blood  vessels  which  the  gland  pos- 
sesses, combined  with  its  proximity  to  the  larger 
neck  vessels,  caused  some  of  the  older  authors  to 
believe  that  the  thyroid  was  a  sort  of  safety  valve 
for  regulating  the  circulation  of  the  brain. 

Of  more  interest  is  the  physiologic  active  hyperae- 
mia of  the  gland,   which    stands   in   close  relation- 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         19 

ship  to  the  genital  organs,  especially  of  the  female. 
A  visible  enlargement  of  the  gland  may  occur  in 
connection  with  menstruation,  during  pregnancy, 
after  coitus,  and  especially  after  defloration.  Cases 
have  also  been  reported  where  a  distinct  goitre  was 


Fig.  2.  Old,  simple,  diffuse,  symptomless  goitre.  Epithelium 
degenerated  and  the  distended  follicles  filled  with  thick,  stainable 
colloid.     Calcareous  degeneration  in  places.     (Louis  B.  Wilson.) 

present  during  the  period  of  conception,  which  sub- 
sided with  the  beginning  again  of  menstruation. 
This  sexual  hyperemia  of  the  thyroid  is  so  constant 
that  in  certain  southern  countries  zealous  mothers 
measure  the  neck  of  the  bride  before  and  after  the 
marriage  night. 


20  THYROID    GLAND 

Haemorrhage  is  more  frequently  found  in  goitre 
than  in  the  normal  thyroid,  although  any  trauma  of 
the  thyroid  may  .result  in  haemorrhage  into  the  acini 
or  into  the  stroma  of  the  gland. 

Infarction  and  embolism  of  the  thyroid  can  be 
practically  disregarded  owing  to  the  free  anasto- 
moses in  this  organ. 

Passive  congestion  of  the  thyroid  may  occur,  but 
it  rarely  causes  changes  of  importance.  Destruction 
of  the  blood  supply  of  the  gland,  as  by  ligation  of 
the  thyroid  arteries,  leads  to  atrophy  of  the  thyroid. 
This  ligation  of  the  thyroid  arteries  was  first  prac- 
ticed for  the  treatment  of  goitre  by  Wolfler  in  1886. 
The  possibility  of  leaving  in  the  neck  a  beginning 
malignant  growth  instead  of  a  simple  goitre  was  an 
objection  urged  at  once  by  von  Bergmann  against 
this  operation. 

Inflammation.  Primary  acute  inflammation  of 
the  thyroid  gland  (thyroiditis)  is  almost  never  seen. 
Acute  inflammation  of  a  goitrous  gland  may  be 
occasionally  observed.  In  general  septicaemia,  with 
involvement  of  various  organs,  the  thyroid  is  rarely 
included,  as  it  is  one  of  the  most  resistant  of  all  the 
tissues.  However,  in  connection  with  certain  in- 
fectious diseases,  acute  inflammation  of  the  thyroid 
has  been  described.  So  we  find  an  occasional  rare 
case  of  thyroiditis  reported  following  such  infections 
as  puerperal  fever,  influenza,  typhoid  fever,  diph- 
theria, erysipelas,  orchitis,  acute  articular  rheuma- 
tism and  similar  infections. 

These  acute  inflammations,  when  they  do  occur, 
are  usually  purulent.  Pus  accumulation  (abscess) 
is  found  in  the  majority  of  these  cases.     Rupture  of 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         21 

the  abscess  and  healing  by  cicatrization  may  occur, 
or  simple  resolution  may  take  place.  Sometimes 
abscesses  may  rupture  into  the  trachea,  oesophagus 
or  mediastinum,  causing  death. 

Gangrene  as  a  result  of  acute  infection  has  occurred, 
but  such  an  outcome  is  extremely  rare.  Perhaps 
seven  or  eight  such  cases  have  been  reported.  Also 
sufficiently  rare  to  be  of  interest  are  the  few  cases 
where  thyroid  destruction  by  acute  inflammation 
has  been  sufficient  to  cause  symptoms  of  myxoedema. 

Chronic  Inflammation.  Chronic  interstitial  thy- 
roiditis may  be  found  in  very  young  individuals 
(primary  infantile  atrophy)  or  in  older  individuals 
without  giving  rise  to  any  symptoms  of  hypothy- 
roidism. In  such  cases  the  gland  is  diminished  in 
size  and  the  parenchyma  is  replaced  to  a  greater  or 
less  extent  by  connective  tissue. 

The  atrophy  of  old  age  is  to  be  distinguished  from 
the  sclerosis  due  to  a  chronic  inflammatory  process, 
although  the  increase  in  stroma  and  decrease  in 
colloid  and  epithelial  elements  gives  practically  the 
same  histologic  picture. 

The  thyroid  has  been  found  atrophic  in  sclero- 
derma (Hektoen)  and  in  icthyosis  (Moore  and  War- 
field). 

Tuberculosis.  Tuberculosis  of  the  thyroid  is  a 
comparatively  rare  finding,  but  careful  search  of  the 
gland  will  sometimes  reveal  tubercular  foci  in  con- 
nection with  cases  of  wide-spread  general  tubercu- 
losis, especially  acute  miliary  tuberculosis.  Fraenkel 
found  the  thyroid  involved  six  times  in  fifty  cases, 
the  lesions  usually  appearing  as  miliary  tubercles, 
although  rarely  a  large  caseous  nodule  was  found. 


22 


THYROID    GLAND 


The  tubercles  arise  in  the  interstitial  tissue  between 
the  follicles.  The  latter  are  compressed,  stellate 
at  times,  with  their  walls  pressed  together,  and  their 
content  and  lining  epithelium  degenerated  or  lost 
altogether. 

Ruppanner  has  recently  described,  in  addition  to 


Fig.  3.  Very  early;  mild  Graves'  disease.  Sections  show  small 
intra-alveolar  parenchyma  increase,  with  small  amount  of  thin  secre- 
tion.   (Louis  B.  Wilson.) 

the  interstitial  form,  an  intrafollicular  tubercular 
process  in  the  thyroid,  and  also  differentiates  between 
miliary  and  chronic  tuberculosis  of  the  gland. 

Syphilis.     Syphilis  of   the  thyroid  gland  is  much 
more  rare  at  the  present  day  than  it  Was  formerly. 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         23 

Practically  the  only  instances  seen  now  are  in  con- 
nection with  visceral  syphilis  of  infants,  in  which 
the  thyroid  may  show  pea-sized,  or  smaller,  gum- 
matous nodules,  grayish  red  or  grayish  yellow  in 
color,  with  typical  microscopic  structure,  such  as 
new  formation  of  connective  tissue,  with  lymphoid  and 
plasma  cell  infiltration  and  destruction  of  paren- 
chyma, but  showing  less  tendency  to  necrosis  than 
the  tubercular  nodules. 

Certain  cases  of  general  thyroid  enlargement  in 
connection  with  tertiary  syphilis  have  been  reported, 
which  disappeared  under  syphilitic  treatment,  but 
recurred  with  the  other  symptoms  on  discontinu- 
ance of  the  treatment. 

Degeneration  and  Infiltration.  While  various 
forms  of  degeneration  may  occur  in  the  normal 
thyroid,  these  processes  are  much  more  frequently 
met  with  in  goitre,  and  are  sometimes  so  marked  as 
to  give  the  title  of  the  degeneration  to  the  goitre — - 
e.  g.,  "calcified  goitre,"  a  term  that  is  lacking  in  the 
true  significance  of  the  process. 

Slight  parenchymatous  changes  have  been  de- 
scribed in  connection  with  acute  infectious  diseases, 
but  the  thyroid  is  so  variant  in  its  histology  that  it 
is  difficult  to  state  when  such  changes  are  actually 
present.  Thus  Torri  described  hypersecretion  of 
colloid  and.  new  formation  of  epithelium,  which  goes 
on  to  progressive  changes  if  the  disease  is  long  con- 
tinued, in  connection  with  acute  infections. 

Hyaline  degeneration  is  of  little  importance,  and 
fatty  change  is  rarely  observed,  save  in  degenerated 
areas,  especially  of  goitres.  The  epithelium  of  the 
thyroid    normally    contains    some    fat    (Erdheim). 


24  THYROID   GLAND 

Calcification,  and  at  times  ossification,  is  seen,  par- 
ticularly in  old  age.  In  goitre,  calcified  areas  are 
very  common.  Old  cyst  walls  may  be  completely 
infiltrated  with  lime  salts. 

Amyloid  infiltration  may  be  found  in  connection 
with  cases  of  amyloidosis,  but  is  much  less  often 
present  in  the  thyroid  than  in  the  liver,  spleen  and 
other  parenchymatous  organs.  It  is  found,  when 
present,  deposited  in  the  walls  of  the  arteries  and  in 
the  stroma  of  the  gland. 

Hypothyroidism.  Lack  of  thyroid  function,  as 
brought  about  by  congenital  defect  or  degeneration', 
or  removal  of  the  thyroid  gland,  is  followed  or  ac- 
companied by  certain  disturbances,  the  most  com- 
mon of  which  are  swelling  of  the  subcutaneous 
tissues,  falling  of  the  nails  and  hair,  stupidity,  idiocy 
and  skeletal  disturbances.  The  various  cases  that 
come  under  this  head  lend  themselves  to  the  fol- 
lowing classification  (Ewald). 

1. — Endemic  Cretinism,  a  chronic  disease  found 
in  regions  where  goitre  is  endemic,  manifesting  itself 
through  skeletal  deformity,  skin  and  subcutaneous 
tissue  changes,  lack  of  genital  development,  diminu- 
tion in  intellect  and  sense  function.  Such  cases 
show  changes  in  the  thyroid  gland,  consisting  of 
partial  or  complete  degeneration,  which  maybe  either 
atrophic  or  goitrous  in  its  inception,  or,  as  Getzowa 
has  described,  cases  are  found  in  which  atrophic 
areas  and  goitrous  degenerated  nodules  alternate 
in  the  same  gland. 

2. — Sporadic  Cretinism,  a  similar  condition  to  the 
above,  due  to  congenital  absence  of  the  thyroid 
gland  (thyroaplasia) . 


THE  PATHOLOGY  OF  THE  THYROID  GLAND    25 

3.— Infantile  myxoedema,  due  to  acquired  loss  or 
perversion  of  thyroid  function  in  the  early  years  of 
life,  and  therefore  showing  greater  or  less  severity  of 
symptoms,  according  to  the  amount  of  functional 
disturbance  of  the  gland.  Under  this  head  may  be 
included  the  abortive  cases  of  myxoedema  (myxoe- 
deme  f ruste) . 

4. — Adult  myxoedema,  a  spontaneous  hypo,  or 
athyreosis  of  adults.  In  these  cases  the  thyroid  gland 
is  usually  diminished  in  size  and  atrophic,  pale  yel- 
lowish white  in  color,  firm  in  consistence.  Micro- 
scopically the  parenchyma  is  replaced  by  dense 
fibrous  tissue.  Degenerated  epithelial  cell  nests, 
small  cysts  containing  fat  and  cholesterin,  and  areas 
of  lymphoid  and  plasma  cell  infiltration  may  be 
found.  In  addition  to  the  changes  in  the  thyroid, 
peculiar  changes  are  found  in  the  corium  (thicken- 
ing and  fracture  of  the  connective  tissue  fibres,  in- 
filtration with  gelatinous  like  material). 

5. — Operative  myxoedema  (cachexia  strumipriva 
or  thyropriva),  a  condition  due  to  the  operative 
(complete)  removal  of  a  goitre  or  the  normal  thyroid 
gland.  This  latter  condition  has  been  fully  dis- 
cussed in  the  chapters  on  the  parathyroid  glands. 

Hypertrophy  (Goitre).  Although  we  can  not  al- 
ways make  a  sharp  distinction  between  new  growth, 
in  the  tumor  sense,  and  hypertrophy,  especially  in 
the  circumscribed  forms  as  they  occur  in  the  thyroid 
gland,  still  the  ordinary  goitre  (struma)  probably 
best  lends  itself  to  the  above  classification. 

We  recognize  two  main  foims  of  hypertrophy  or 
simple  goitre :    1,  diffuse;  2,  nodular. 


26  THYROID    GLAND 

In  diffuse  goitre  we  have  a  uniform  enlargement 
of  the  thyroid  gland,  or  perhaps  one  lobe  of  the  gland 
is  frequently  considerably  more  enlarged  than  the 
other,  but  presents  no  circumscribed  nodules  differ- 
ing in  structure  from  the  rest  of  the  lobe.  Occasion- 
ally, however,  a  more  rapidly  proliferating  area  may 
be  encountered  in  such  a  thyroid  than  is  shown  in 
the  adjoining  tissue,  but  such  areas  are  not  sharply 
bounded. 

This  diffuse  type  of  hypertrophy  may  show  itself 
in  two  forms:  (a)  Colloid  goitre.  In  this  type  the 
amount  of  colloid  is  so  greatly  increased  that  the 
follicles  of  the  gland  are  often  greatly  dilated,  and  the 
epithelium  lining  the  same  more  or  less  flattened,  or 
finally  completely  destroyed,  by  the  pressure  of  the 
increased  colloid  content.  The  septa  between  neigh- 
boring follicles  may  be  broken  through  by  strong 
pressure  and  subsequently  absorbed.  If  sufficient 
dilatation  and  confluence  of  follicles  is  brought  about 
by  this  process,  we  can  finally  have  the  appearance 
of  considerable  sized  cysts  (cystic  colloid  goitie). 

(b).  Parenchymatous  goitre.  This  type  of  hyper- 
trophy consists  of  a  glandular  proliferation  that  is 
more  in  the  order  of  a  new  formation  in  the  tumor 
sense.  Solid  cell  masses  and  cords,  together  with 
connective  tissue,  form  follicles  much  in  the  same 
manner  as  they  are  built  up  in  the  foetal  thyroid. 
The  colloid  content  is  usually  scant,  or  may  be  alto- 
gether lacking.  The  epithelium  lining  the  follicles 
may  be  cylindric,  and  sometimes  forms  papillary 
projections  into  the  lumina  of  the  follicles.  By  en- 
largement of  the  follicles  and  continued  papillary 
ingrowth  into  the  same,  we  may  have  a  variation  of 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         27 

type,    which   has   been   designated   papillary   cystic 
goitre. 

These  two  types  of  diffuse  goitre  just  described 
are  widely  different  in  regard  to  their  clinical  signifi- 
cance.    In  the  first  type  (a)  the  functioning  epithe- 


Fig.  4.  Acute  stage  of  Graves'  disease.  Sections  show  increased 
alveolar  parenchyma,  papillae  formation,  and  a  large  amount  of  non- 
staining  secretion.     (Louis  B.  Wilson.) 

lium  of  the  gland  is  more  or  less  completely  destroyed 
and  the  colloid  usually  non-absorbable ;  therefore 
such  goitres  are  not  associated  with  hyperthyroid- 
ism.    In  the  second  type  (b),    on  the  contrary,  we 


28  THYROID    GLAND 

have  an  increased  amount  of  functioning  tissue,  and 
it  is  from  such  goitres  that  hyperthyroidism  (Graves' 
disease)  arises. 

Marine  and  Lenhart  have  shown  that  in  the  dog 
one  can  carry  a  thyroid  gland  through  a  variety  of 
stages  of  goitre.  By  partial  removal  of  a  thyroid, 
for  example,  one  may  produce  an  active  hyper- 
plasia, as  was  originally  shown  by  Halsted.  This 
hyperplastic  type  of  gland  may  be  reduced  to  a  simple 
colloid  type  by  the  administration  of  iodine.  By 
means  of  partial  removals,  together  with  withholding 
and  giving  iodine,  one  may  follow  the  process  of 
reversion  of  a  hyperplasia  to  colloid,  produce  again 
a  second  hyperplasia,  and  finally  obtain  a  secondary 
reversion  to  colloid  in  the  same  animal.  It  is  in- 
teresting to  note  that  these  authors  find  that  an 
actively  proliferating  thyroid  (hyperplasia)  may  re- 
vert to  a  pure  colloid  goitre  within  a  month. 

Nodular  goitre  is  characterized  by  the  occurrence 
in  the  thyroid  gland  of  circumscribed  nodules,  vary- 
ing in  number  and  size,  between  which  either  normal 
or  completely  degenerated  or  atrophic  thyroid  tissue 
appears.  Even  the  smallest  (microscopic)  nodules 
show  a  distinct  connective  tissue  capsule.  The 
nodules  may  present  the  typical  picture  described 
under  colloid  goitre,  or  may  be  of  the  parenchyma- 
tous type.  Sometimes  in  the  same  gland  nodules 
of  both  types  may  appear.  In  these  nodules  various 
degenerative  processes  are  frequently  encountered, 
such  as  hyaline  and  fatty  change.  A  nodule  may 
undergo  complete  connective  tissue  transformation 
(fibrous  goitre),  or  lime  salts  may  be  deposited  in 
the  same  (calcified  goitre) .     Through  breaking  down 


THE    PATHOLOGY    OF    THE    THYROID    GLAND 


29 


and.  absorption  of  the  content  of  such  nodules,  cysts 
may  frequently  arise,  which  through  haemorrhage 
may  show  a  red  brown  or  deeper  brown  colored  content. 
A  combination  of  these  various  degenerative  process- 
es in  the  same  nodule  gives  rise  to  the  multicolored 
appearance  frequently  seen  on  fresh  section  of  the 
same. 

Still  another  variation  of  the  nodular  form   of 
goitre  is  to  be  found  in  the  so-called  foetal  adenoma 


Fig.  5.     Foetal  adenoma  of  the  thyroid,  with  acini  in  various 
stages  of  development  and  edge  of  a  large  cyst.     (Louis  B.  Wilson.) 

of  the  thyroid,  which  consists  of  encapsuled  nodules 
made  up  of  cells  corresponding  to  the  undifferen- 
tiated cell  rests  of  embryonal  thyroid.  The  develop- 
ment of  these  latter  nodules  may  in  certain  instances 
give  rise  to  hyperthyroidism. 

Hyperthyroidism  (Graves'  Disease,  Basedow's  Dis- 
ease,   Exophthalmic    Goitre).     In  connection  with 


30  THYROID    GLAND 

certain  types  of  thyroid  hypertrophy  (parenchy- 
matous goitre,  papillary  cystic  goitre,  and  sometimes 
foetal  adenoma  of  the  thyroid,  according  to  the  class- 
ification of  MacCarty),  we  have,  in  addition  to  the 
struma,  the  appearance  of  certain  phenomena,  such 
as  exophthalmos,1  heart  palpitation,  tremor  of  the 
hands,  and  nervous  symptoms,  especially  of  vaso- 
motor type,  in  varying  degrees  of  prominence.  Au- 
topsies on  such  individuals  show,  in  addition  to  the 
changes  in  the  thyroid,  usually  dilatation  of  the  heart, 
more  or  less  wide-spread  fatty  muscle  atrophy,  par- 
enchymatous myocarditis,  and  frequently  a  persist- 
ent thymus  and  splenic  enlargement. 

It  is  in  the  hyperactive  thyroid  that  we  seek  an 
explanation  for  these  symptoms,  and  the  recent 
work  of  Dr.  Louis  B.  Wilson  has  shown  that  there 
is  a  definite  parallel  between  the  increased  amount 
of  functioning  tissue  and  absorbable  secretion  in  the 
thyroid  gland  and  the  degree  of  severity  of  the  symp- 
toms. 

So  we  may  have  hyperthyroidism  result  from  a 
simple  goitre  by  increase  in  function  of  the  thyroid 
gland;  or,  on  the  other  hand,  by  continued  activity, 
degenerative  changes  may  appear  in  the  function- 
ing cells,  and  blocking  of  the  lymphatic  drainage 
take  place,  so  that,  provided  the  patient  lives  long 
enough,  a  case  of  hyperthyroidism  can  return  to  a 
simple  goitre.     In  such  cases,   however,   the  heart 

(1)  If  we  take  for  granted  hyperthyroidism  as  the  cause  of  exophthalmos,  we  are 
still  considerably  in  doubt  as  to  how  the  action  is  brought  about.  The  phenomenon 
can  not  rest  on  so  simple  an  explanation  as  increased  fatty  tissue,  congestion  or 
edema  within  the  orbit.  Muscular  spasm,  sympathetic  irritation,  vasomotor  con- 
gestion and  what  not  have  been  assumed.  A  mechanical  basis  for  its  occurrence 
has  been  offered  by  Landstroem,  who  has  recently  described  a  new  muscle  within  the 
orbit.  This  muscle,  which  consists  of  a  cylindric  band  of  smooth  muscle  fibres,  has 
its  origin  in  the  orbital  septum  and  its  insertion  into  the  equator  bulbi.  The  cone- 
like insertion  is  sufficient  to  pull  the  eyeball  forward  and  produce  exophthalmos  under 
the  sympathetic  irritation  which  is  assumed  as  a  result  of  the  hyperthyroidism. 


THE    PATHOLOGY    OF    THE    THYROID    GLAND        31 

and  nervous  symptom  may  persist  as  a  result  of 
the  previous  over  action  of  the  thyroid  for  a  consider- 
able time  after  the  thyroid  has  become  quiescent. 
It  is  in  such  cases  that  Wilson  has  warned  against 
operative  interference. 

The  thyroid  gland  itself  in  hyperthyroidism  while 
usually  increased  in  size  is  not  necessarily  always 
large,  it  is  firm  in  consistence,  and  decidedly  vascu- 
lar, especially  in  acute  cases. 

Microscopically  the  important  change  is  the  paren- 
chyma increase  which  may  appear  within  the  alveoli 
as  a  cellular  increase  in  a  single  layer,  or  there  may 
be  a  reduplication  of  layers.  In  many  instances 
this  cellular  increase  is  brought  about  by  infolding 
of  the  alveolar  wall,  or  papillas  formation  within  the 
alveoli.  In  a  second  type  of  case  there  is  an  actual 
increase  in  the  number  of  alveoli  (adenoma  type). 
The  acute  cases  also  show  a  considerable  amount  of 
thin,  non-eosin  staining  secretion) .  The  more  chronic 
cases  show  degenerative  changes  consisting  of  des- 
quamation of  the  alveolar  epithelium  and  denser 
staining  of  the  secretion. 

Wilson  has  been  able  to  classify  the  pathological 
findings  in  this  condition  very  closely  with  the  clini- 
cal symptoms.  Eighty  per  cent,  of  his  cases  showed 
a  remarkable  parallel  between  the  pathologic  finding 
in  the  thyroid  gland  and  the  condition  of  the  patient. 
According  as  to  whether  the  cases  were  acute,  and 
mild,  moderate  or  severe,  there  was  a  rising  increase 
of  functional  activity  as  shown  by  increased  paren- 
chyma and  increased  absorbable  secretion  in  the 
thyroid  gland.  Cases  that  had  been  severe  but  with 
remission  of  symptoms  at  the  time  of  examination 


32 


THYROID    GLAND 


showed  microscopically  beginning  degeneration.  Cases 
that  had  been  severe  but  that  had  reduced  them- 
selves to  the  residual  stage  where  only  heart  and 
nervous  symptoms  persisted  as  a  result  of  the  pre- 
vious intoxication,  showed  histologically  more  or 
less  complete  degeneration  in  the  thyroid  gland. 

The  extent  of  the  pathological  process  in  the  thy- 
roid is  not  always  to  be  brought  in  line  with  the 


\\1 

p. 

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Fig.  6.     Showing  lateral  compression  of  the  trachea  by  a  large 
goitre. 

severity  of  the  symptoms,  however,  as  the  patient's 
ability  to  neutralize  the  increased  secretion  has  to 
be  taken  into  account. 

Tumors.  Simple  histoid  growths,  such  as  fibroma, 
chondroma,  osteoma,  etc.,  may  be  found  in  the 
thyroid  gland  and  show  no  peculiarities  worthy  of 


THE    PATHOLOGY    OF    THE    THYROID    GLAND         33 

note  in  this  situation.  More  complicated  structures, 
including  teratoma  in  which  all  three  germ  layers 
are  present,  have  been  found  in  the  gland. 

Sarcoma.  Primary  sarcoma  of  the  thyroid  is 
very  rare;  less  than  a  hundred  authentic  cases  have 
been  reported.  Most  of  these  cases  have  appeared 
in  the  middle  years  of  life,  and  have  been  found  more 
frequently  in  women  than  in  men.  They  have  also 
been  found  more  often  in  an  already  goiterous  gland 
than  in  the  normal  thyroid. 

Histologically  these  growths  may  be  of  almost  any 
sarcoma  type,  although  the  round  cell  and  spindle 
cell  varieties  are  most  frequently  met  with.  Giant 
cell  and  osteoplastic  growths  have  been  described, 
as  well  as  tumors  classified  as  perithelioma  and  endo- 
thelioma. 

The  sarcomatous  cell  growth  is  infiltrative  in  type, 
rarely  encapsulated,  and  sometimes  so  completely 
destroys  the  gland  that  no  recognizable  thyroid 
tissue  can  be  found.  These  tumors  may  become  so 
large  as  to  cause  dangerous  pressure  symptoms. 
Metastasis  from  such  growths  may  take  place  by 
both  blood  and  lymph  channels. 

Carcinoma.  Primary  malignant  epithelial  new 
growths  are  also  rare  in  the  thyroid  gland.  Less 
than  one  per  cent  of  all  carcinoma  has  its  origin  in 
this  location;  moreover,  the  disease  is  more  common 
in  goiterous  regions,  as  cancer  develops  oftener  in 
struma  than  in  the  normal  thyroid.  The  interest- 
ing work  of  L.  Pick  on  carcinoma  of  the  trout 
has  emphasized  the  coincidence  of  goitre  and  car- 
cinoma. The  growth  is  usually  of  the  medullary 
type,  soft  in  consistence,  scant  in  connective  tissue, 


34  THYROID   GLAND 

and  according  to  its  blood  content,  gray  white  to 
dark  red  in  color.  Areas  showing  degeneration 
and  haemorrhages  are  frequent.  Owing  to  lack  of 
encapsulation  the  growth  may  penetrate  the  trachea 
or  the  skin  by  direct  extension.  Frequently  there  is 
growth  directly  into  the  thyroid  veins  or  their 
branches,  emboli  from  which  lead  to  wide-spread 
metastases. 

At  times  the  structure  of  these  malignant  growths 
bears  a  close  resemblance  to  actively  proliferating 
goitre,  or  even  to  normal  thyroid  gland,  so  that 
histological  differentiation  as  to  malignancy  is  ex- 
tremely difficult,  or  at  times  impossible;  the  metas- 
tatic nodules  in  the  lungs,  liver,  bone,  etc.,  for  in- 
stance, corresponding  almost  identically  with  normal 
thyroid  gland. 

Adenocarcinoma  types,  with  widening  of  the  gland 
follicles  and  papillary  ingrowths  may  sometimes 
appear  so  that  a  so  called  papillary  cystocarcinoma 
is  formed. 

In  addition  to  metastasis  through  direct  ingrowth 
into  the  veins  and  subsequent  vascular  embolism, 
the  lymphatics  may  be  invaded.  As  a  rule  greatly 
enlarged  neighboring  lymph  nodes  accompany  these 
growths.  The  lungs  are  the  most  favorable  site  for 
metastasis;  more  rarely  other  internal  organs  are 
included. 

Bone  metastases  are  especially  to  be  noted  in  con- 
nection with  these  malignant  thyroid  tumors,  which 
apparently  find  a  most  suitable  opportunity  for 
growth  in  bone  marrow.  This  favorable  influence 
of  bone  marrow  on  thyroid  proliferation  is  borne 


THE    PATHOLOGY    OF    THE    THYROID    GLAND        35 

out  by  the  fact  that  such  a  situation  is  best  adapted 
to  successful  thyroid  transplantation. 

A  rare  but  interesting  form  of  tumor  is  a  malig- 
nant growth  found  usually  in  bone  which  may 
metastasize  to  other  organs,  but  which  possesses  the 
typical  structure  of  normal  thyroid  gland  or  of 
simple  goitre.  Such  tumors  are  made  up  of  typical 
follicles  filled  with  iodine  containing  colloid.  The 
thyroid  gland  in  such  cases  may  be  free  from  any 
tumor  growth.  Fabris  has  reported  such  a  case, 
which  was  diagnosed  Pott's  disease,  but  at  autopsy 
the  vertebra  were  found  to  be  filled  with  a  tumor 
growth  corresponding  histologically  with  thyroid 
tissue. 

Mixed  tumors  of  the  thyroid  which  have  been  oc- 
casionally observed,  i.  e.,  growths  apparently  of 
both  connective  tissue  and  epithelial  origin — sarco- 
carcinoma — are  best  explained  by  the  experimental 
tumors  of  Ehrlich  and  Apolant. 

Two  such  cases  have  been  reported  by  Teacher, 
and  a  case  of  Schmorl's  is  distinctly  of  this  type. 
In  the  latter  case  an  adenoma  of  the  thyroid  was 
removed  at  operation.  After  a  time  the  tumor  re- 
curred and  this  examination  showed  carcinoma  and 
sarcoma  in  about  equal  amount.  Finally  the  patient 
died  from  metastases,  which  presented,  histologic- 
ally, the  structure  of  pure  spindle  cell  sarcoma. 


CHAPTER  III. 
DIAGNOSIS. 


The  diagnosis  of  goitre  in  itself  is  exceedingly 
simple  because  of  the  definite  location  of  the  thyroid 
gland  and  its  attachment  to  the  trachea  which 
causes  it  to  move  upwards  with  the  larynx  during  the 
act  of  swallowing.  Normally  the  form  of  the  thyroid 
gland  is  quite  regular  as  shown  in  our  anatomical 
illustrations  and  whenever  there  is  a  uniform  en- 
largement of  the  gland,  the  larger  it  becomes  the 
easier  it  is  to  make  the  diagnosis.  This  uniform  en- 
largement of  the  gland  is,  however,  not  the  rule  and 
usually  the  distortion  increases  with  the  extent  of 
enlargement.  There  seems  to  be  no  definite  rule  as 
to  the  number  of  lobes  that  are  to  be  involved  when 
the  enlargement  has  once  begun  to  become  apparent. 
It  is,  however,  more  common  to  find  the  middle  lobe 
and  one  lateral  lobe  enlarged  than  to  find  both 
lateral  lobes  affected  with  the  middle  lobe  in  a 
normal  condition.  Most  commonly  one  lateral  lobe 
is  greatly  enlarged,  the  middle  lobe  considerably 
and  the  other  lateral  lobe  but  slightly. 

The  differential  diagnosis  may  sometimes  be  some- 
what difficult  between  goitre  and  branchial  cyst  but 
the  latter  is  usually  more  uniform.  There  is  usually 
distinct  fluctuation  present  in  the  latter  condition 
and  the  normal  thyroid  gland  can  be  felt  usually 
below  the  branchial  cyst. 


DIAGNOSIS  37 

Enlarged  lymph  nodes  due  to  leukaemia  or  pseud  o- 
leukasmia  are  definitely  composed  of  separate  more 
or  less  spherical  glands  which  are  arranged  along 
the  anterior  or  posterior  border  of  the  sterno-cleido- 
mastoid  muscle,  or  in  the  vicinity  of  the  submaxil- 
lary, salivary  or  the  parotid  glands. 

Moreover,  the  first  nodules  usually  appear  high 
up  in  the  neck  and  not  in  the  region  of  the  thyroid 
gland. 

Diffuse  or  dissecting  lipoma  of  the  neck  is  likely  to 
begin  on  the  posterior  surface  of  the  neck  and  to 
progress  downwards  and  forward. 

Lymphosarcoma  may  occur  at  any  point  in  the 
neck  usually  in  front  of  the  sterno-cleido-mastoid 
muscle.  It  is  only  slightly  movable,  if  at  all,  and 
neither  this  nor  the  preceding  two  forms  of  enlarge- 
ment move  up  and  down  with  the  larynx  at  degluti- 
tion. 

Carcinoma  in  the  lymph  nodes  of  the  neck  will  not 
be  mistaken  for  goitre  upon  careful  examination  be- 
cause the  former  is  always  secondary  to  carcinoma 
of  the  mouth,  pharynx,  nose,  scalp,  parotid  gland 
or  ear  or  some  other  tissue. 

Occasionally  the  primary  tumor  is  very  small  and 
in  this  way  it  may  be  overlooked,  but  even  in  this 
case  the  masses  do  not  rise  and  fall  with  the  larynx, 
and  the  normal  gland  can  usually  be  outlined  in  its 
proper  position  by  making  a  careful  examination. 
The  surgeon  is  rarely  called  upon  to  treat  simple 
goitre  until  it  has  advanced  to  a  considerable  size 
so  that  the  growth  is  a  source  of  annoyance  to  the 
patient  because  of  the  deformity  it  produces,  or  be  - 


38  THYROID   GLAND 

cause  of  the  fact  that  the  pressure  from  the  tumor 
interferes  with  respiration  or  deglutition.  Occasion- 
ally these  symptoms  exist  in  cases  in  which  inspec- 
tion does  not  reveal  an  enlargement  of  the  thyroid 
gland  but  upon  deglutition  a  tumor  will  be  seen  to 
rise  from  under  the  upper  end  of  the  sternum.  In 
these  cases  there  is  a  marked  enlargement  down- 
ward of  a  portion  of  the  middle  lobe  which  presses 
forward  against  the  sternum  and  backward  against 
the  trachea.  In  a  few  instances  I  have  encountered 
such  a  lobe  projecting  inward  and  downward  from 
the  lower  end  of  one  of  the  lateral  lobes  extending 
quite  behind  the  upper  end  of  the  sternum  and  giv- 
ing, rise  to  severe  obstruction  to  respiration. 

THE  DIAGNOSIS  OF  EXOPHTHALMIC  GOITRE. 

There  is  no  disease  in  which  familiarity  through 
repeated  contact  is  of  greater  aid  in  making  a  diag- 
nosis than  in  exophthalmic  goitre.  The  earlier  ob- 
servers like  Parry,  Graves,  Basedow,  Desmarres 
and  Trousseau  placed  especial  stress  upon  two  ele- 
ments contained  in  the  name  exophthalmos  and  goitre 
to  which  the  symptom — which  later  became  the 
most  important  of  all — tachycardia  was  soon  added. 
Later  many  other  symptoms  which  will  be  described 
in  detail  were  added  from  time  to  time,  but  we  must 
bear  in  mind  that  in  England  the  description  of  the 
disease  by  Parry  and  Graves,  in  Germany  by  von 
Basedow,  in  France  by  Charcot  and  Trousseau,  and 
in  Italy  by  Flajani  had  thoroughly  established  this 
as  a  distinct  disease  before  any  of  the  following 
symptoms  had  been  shown  to  be  present  in  exoph- 
thalmic goitre.     Recently  it  has  been  claimed  by 


DIAGNOSIS 


39 


several  clinicians  that  a  diagnosis  of  this  disease  can 
and  must  be  made  in  case  tachycardia  is  present 
which  cannot  be  explained  upon  any  other  patho- 
logical theory  in  any  given  case  especially  if  several 
of  the  other  symptoms,  but  neither  exophthalmos 
nor  goitre  are  present.  When  either  of  these  two 
symptoms  is  present  with  tachycardia  all  authorities 
agree  on  the  diagnosis. 


Fig.  7.     Exophthalmic   goitre,     lateral   view    of  neck,    showing 
moderate  enlargement  of  thyroid  gland. 

This  has  given  rise  to  a  serious  objection  to  the 
term  exophthalmic  goitre  because  it  was  argued 
that  a  disease  with  a  description  name  should  at 
least  in  part  conform  with  this  description. 

Since  the  disease  has  been  definitely  accepted  as  a 
condition,  due  according  to  Moebius  to  an  increased 
pathological  activity  of  the  thyroid  gland,  those  who 


40  THYROID    GLAND 

have  most  carefully  studied  the  specimens  removed 
by  operation  have  always  been  able  to  find  some  por- 
tion of  the  gland  with  the  typical  pathological 
structure  of  the  thyroid  gland  even  in  cases  in  which 
from  external  examination  the  pressure  of  a  goitre 
could  not  be  definitely  demonstrated.  In  my  own 
cases  it  was  always  possible  to  demonstrate  even  in 
the  gross  specimen  some  portion  that  showed  the 
presence  of  hypertrophy  and  histologically  every 
case  showed  typical  tissue  in  some  portion.  It  is 
true  that  there  is  often  a  marked  discrepancy  be- 
tween the  extent  of  the  goitre  and  the  degree  of 
tachicardia,  tremor,  muscular  weakness  and  other 
symptoms.  When  one  bears  in  mind,  however,  that 
very  minute  quantities  of  any  one  of  a  number  of 
active  drugs  with  which  we  are  familiar  when  intro- 
duced into  the  circulation  produce  exceedingly  vio- 
lent symptoms  it  is  easy  to  understand  how  the 
secretion  from  a  very  small  portion  of  diseased  tissue 
in  the  thyroid  gland  may  produce  all  of  the  symp- 
toms of  this  disease.  All  of  these  symptoms  may  be 
intermittent.  There  may  be  a  marked  difference  in 
the  size  of  the  thyroid  gland  from  week  to  week,  the 
eyes  may  be  so  prominent  one  day  that  they  will  at- 
tract attention  at  once  at  one  time  and  a  few  weeks 
later  this  symptom  may  be  scarcely  perceptible.  In 
the  same  manner  the  pulse  may  vary  from  eighty  to 
one  hundred  and  sixty  beats  per  minute,  although  it 
rarely  remains  under  one  hundred  during  the  entire 
day. 

In  these  cases  there  seems  to  be  a  discharge  into 
the  circulation  of  a  considerable  quantity  of  the 


DIAGNOSIS  41 

poison  at  intervals.    This  may  be  brought  about  by 
mental  or  by  physical  influences. 

I  have  known  severe  sorrow  over  the  death  of  some 
member  of  the  family,  excitement  over  a  fire;  a  sud- 
den fright,  overwork,  both  physical  or  mental,  anx 
iety  and  fatigue  during  a  political  campaign,  excite- 
ment in  social  life  and  many  other  similar  conditions 
to  give  rise  to  severe,  sometimes  fatal  exacerbations 
of  this  condition. 

In  each  case  it  has  seemed  as  though  the  patient 
could  not  quite  return  to  the  condition  in  which  he 
was  before  the  last  exacerbation  and  although  the 
next  attack  might  not  be  more  severe  than  the  pre- 
vious one  still  its  effect  upon  the  patient  seemed  at 
least  somewhat  more  severe. 

MINOR    SYMPTOMS. 

Before  enumerating  the  minor  symptoms  of  ex- 
ophthalmic goitre  it  will  be  well  once  more  to  insist 
upon  the  fact  that  in  the  presence  of  tachycardia 
together  with  even  the  slightest  degree  of  exophthal- 
mos or  enlargement  of  the  thyroid  gland,  a  positive 
diagnosis  of  exophthalmic  goitre  can  always  be 
made. 

In  some  instances  the  changes  in  the  thyroid  gland 
may  be  so  slight  that  only  some  insignificant  irregu- 
larity may  be  noticed,  still  upon  excision  of  this  por- 
tion of  the  gland  the  pathological  condition  is  so  typi- 
cal that  there  can  be  no  doubt  regarding  the  correct- 
ness of  the  diagnosis  when  the  histological  examina- 
tion has  been  made.  I  am  so  persistent  in  impressing 
this  fact  because  this  is  really  the  only  class  of  cases 
which  is  likely  to  be  overlooked  by  the  clinician  who 
has  seen  only  a  small  number  of    well    developed 


42  THYROID    GLAND 

typical  cases  while  these  cases  are  regularly  over- 
looked by  those  who  must  depend  upon  description 
of  the  disease  for  a  basis  upon  which  to  make  a 
diagnosis. 

Fortunately  for  the  patient  one  or  more  of  the 
following  symptoms  will  be  found  in  almost  every 
case  so  that  the  diagnosis  can  be  further  supported. 

At  this  point  it  may  be  well  to  direct  attention  to 
the  fact  that  cases  are  frequently  encountered  in 
which  other  conditions  may  readily  be  mistaken  for 
a  tachycardia.  These  conditions  are  always  due  to 
other  causes. 

Of  these  the  excessive  use  of  nicotin  especially  in 
cigarette  smokers  is  the  most  common  cause  at  the 
present  time.  Myocarditis  due  to  chronic  alcoholism 
is  another  condition  which  is  still  more  misleading 
because  the  alcoholic  tremor  is  almost  identical  with 
the  tremor  of  exophthalmic  goitre  to  be  described 
among  the  minor  symptoms. 

Habitual  users  of  the  various  coal  tar  preparations 
form  another  class  which  may  mislead  the  clinician 
in  making  his  diagnosis.  The  habitual  use  of  a  number 
of  pother  drugs  like  strychnine,  cocaine,  quinine  and 
chloral  must  be  borne  in  mind  in  making  a  diagnosis. 
Similarly  severe  anaemia,  or  marked  obesity,  or  the 
depression  following  severe  illness,  or  unusual  mental 
or  physicial  exertion  especially  when  long  continued 
and  accompanied  with  loss  of  sleep  may  give  rise  to  a 
condition  of  the  heart  which  may  lead  to  a  mistaken 
diagnosis.  Great  sorrow,  severe  fright,  long  con- 
tinued worry  especially  when  accompanied  with  in- 
somnia, exposure  to  great  heat  and  in  fact  any  con- 
dition which  severely  affects  the  nervous  and  circu- 


DIAGNOSIS 


43 


latory  system  may  cause  a  condition  of  the  heart's 
action  which  may  easily  be  mistaken  for  the  tachy- 
cardia of  exophthalmic  goitre.  This  condition  is  fre- 
quently present  after  persons  have  experienced  in- 
juries during  railroad  wrecks. 

It  is  well  to  bear  these  facts  in  mind  especially 
because  any  one  of  these  conditions  may  be  the  ex- 


Fig.  8. 
enlarged. 


Exophthalmic    goitre;    thyroid    gland    only    moderately 


citing  cause  of  an  attack  of  exophthalmic  goitre. 
Moebius  has  reasoned  this  out  in  the  following  man- 
ner :  Many  patients  may  possess  thyroid  glands  that 
are  slightly  pathological  so  that  there  is  a  slight  de- 
gree of  overproduction  of  normal  or  possibly  abnor- 


44  THYROID    GLAND 

mal  secretion  which,  however,  is  either  not  absorbed 
or  if  it  is  absorbed  the  quantity  is  so  limited  that  it 
does  not  make  any  appreciable  impression  upon  the 
tissues  of  the  body  and  especially  the  tissues  of  the 
heart. 

The  patient  may  consequently  live  in  an  appar- 
ently normal  condition  until  there  is  a  severe  de- 
pression due  to  one  of  the  conditions  mentioned 
above  whereupon  the  effect  of  the  thyroid  poisoning 
is  felt  sufficiently  to  give  definite  symptoms,  first  of 
tachycardia  and  later  of  other  typical  conditions 
and' then  the  presence  of  exophthalmic  goitre  is  es- 
tablished. This  thyroid  poisoning  added  to  the  other 
conditions  may  be  sufficient  to  make  the  disease  per- 
manent or  it  may  subdue  as  the  bad  results  of  the 
acute  shock  to  the  general  system  subside  because 
the  amount  of  thyroid  poisoning  may  not  be  sufficient 
even  after  such  an  exacerbation  to  produce  typical 
symptoms. 

It  is  plain,  of  course,  that  such  cases  must  be 
guarded  against  a  repetition  of  acute  strains  of  ah 
kinds  as  the  resistance  against  thyroid  poisoning  as 
has  been  said  above  is  reduced  with  each  successive 
exacerbation. 

Another  theory  may  be  mentioned  at  this  point 
namely  that  there  may  be  an  actual  increase  in  the 
secretion  due  to  the  strain  which  has  temporarily 
been  placed  upon  the  nervous  and  circulatory  sys- 
tems by  any  one  of  the  conditions  mentioned  above. 
Until  some  one  can  determine  by  actual  measure- 
ment the  isolated  poisonous  substance  in  the  circu- 
lation in  patients  suffering  from  exophthalmic  goitre 
it  seems  unlikely  that  the  correctness  of  this  theory 


DIAGNOSIS  45 

will  or  can  be  proven  although  there  is  much  in  the 
course  taken  by  the  disease  that  speaks  in  favor  of 
the  hypothesis. 

For  the  sake  of  clearness  and  brevity  the  minor 
symptoms  will  be  first  enumerated  and  then  dis- 
cussed separately. 

LIST  OF  MINOR  SYMPTOMS. 

1 — Tremor;  2 — Muscular  weakness;  3 — Nervous 
excitability ;  4 — Mental  deficiency ;  5— Vertigo ; 
6— Graefe's  sign;  7— Stellwag's  sign;  8— Moebius' 
sign;     9 — Paroxysmal  dyspnoea; 

10 — Intermittent  vomiting  without  apparent  ex- 
citing cause. 

11 — Intermittent  diarrhoea  without  apparent  ex- 
citing cause. 

12 — Intermittent  sweating  without  apparent  ex- 
citing cause. 

13 — Intermittent  mental  depression  without  ap- 
parent exciting  cause. 

14 — Increase  of  gravity  of  symptoms  upon  psychic 
excitation. 

15 — Increase  of  gravity  upon  mental  fatigue. 

16 — Increase  of  gravity  upon  physical  fatigue. 

17 — Increase  of  gravity  upon  administration  of 
thyroid  extract. 

18 — Increase  of  gravity  upon  administration  of 
iodine. 

19 — Emaciation  in  advanced  cases. 

20 — Anaemia  in  advanced  cases. 

21 — Increased  lymphocytosis,  decreased  poly- 
morphonuclear  leucocytosis. 

22 — Oedema  of  upper  and  lower  eyelids,  later  of  feet. 

23 — Visible  pulsations  in  goitre. 


46  THYROID   GLAND 

24 — Discoloration  of  skin  especially  about  nipples 
and  orifices. 

Any  one  or  any  group  of  these  symptoms  may  be 
prominent  early  in  the  course  of  the  disease.  They 
rarely  precede  the  presence  of  tachycardia  but  fre- 
quently the  appearance  of  exophthalmos  or  marked 
enlargement  of  the  gland  and  frequently  several  of 
these  symptoms  have  developed  to  a  marked  degree 
before  either  exophthalmos  or  enlargement  of  the 
thyroid  gland  can  be  demonstrated. 

It  is  in  these  latter  cases  in  which  a  thorough 
knowledge  of  an  acquaintance  with  these  symptoms  is 
of  especial  importance  in  making  a  diagnosis.  They 
should  always  be  carefully  noted  in  all  cases  in  which 
the  three  major  conditions,  tachycardia,  exophthal- 
mos and  enlargement  of  the  gland  are  present  in 
order  that  the  relation  of  these  conditions  may  be 
recognized  when  found  associated  only  with  tachy- 
cardia. 

1 — Tremor.  The  most  important  minor  symp- 
tom which  can  be  recognized  in  all  advanced  cases 
is  muscular  tremor.  This  was  first  associated  with 
the  disease  by  Charcot  and  later  by  his  pupils 
notably  by  Marie.  The  similarity  between  the  tremor 
of  chronic  alcoholism  and  that  of  exophthalmic 
goitre  further  supports  the  theory  of  Moebius  that 
the  disease  is  due  to  a  condition  of  poisoning  through 
toxic  substances  circulating  in  the  blood  and  affect- 
ing the  tissues  directly.  The  symptoms  can  be  most 
easily  elicited  by  having  the  patient  extend  an  arm 
at  right  angles  with  his  body  or  by  standing  upon 
one  leg  and  flexing  the  other  thigh  with  the  knee 


DIAGNOSIS  47 

extended.  The  latter  test  is  of  course  too  severe  for 
advanced  cases.  Accurate  measurements  have  been 
made  to  determine  the  number  of  contractions  per 
second,  according  to  Marie,  from  8  to  9  oscillations 
take  place  per  second. 

Although  there  seems  to  be  much  uniformity  in 
the  frequency  of  the  oscillations  there  is  a  great 
difference  in  their  severity.     In  many  patients  it  is 


Kjk 

> 

\ 

IgjgfM            | 

Fig.  9.  Lateral  view  of  large  goitre  weighing  seven  pounds  giv- 
ing rise  to  severe  discomfort  because  of  its  weight  and  because  of  the 
direct  pressure  upon  the  trachea  which  caused  marked  obstruction  to 
breathing.  It  also  forced  the  patient  to  hold  her  head  in  a  most  un- 
comfortable position. 

this  tremor  that  first  causes  them  to  consult  the 
physician,  consequently  it  is  necessary  to  bear  the 
relation  between  this  symptom  and  exophthalmic 
goitre  constantly  in  mind  in  order  not  to  overlook 
it  and  make  a  wrong  diagnosis.    In  many  cases  the 


48  THYROID   GLAND 

tremor  remains  permanently  after  it  has  once  ap- 
peared while  in  others  it  may  be  present  at  times 
with  varying  degrees  of  severity  only  to  disappear 
and  reappear  again  at  intervals.  Sometimes  the  tre- 
mor is  so  marked  that  a  look  at  the  patient  from  a 
distance  will  convince  the  trained  observer  that  the 
patient  presents  this  symptom  to  an  extent  which 
will  make  it  necessary  only  to  establish  one  or  two 
other  symptoms  to  confirm  the  diagnosis  of  exophthal- 
mic goitre,  while  in  other  cases  the  most  painstaking 
examination  may  barely  enable  the  most  acute  ob- 
server to  establish  the  presence  Of  this  symptom. 
Whenever  the  symptom  is  present  in  any  given  case 
it  will  usually  appear  in  a  more  marked  form  when- 
ever there  is  an  exacerbation  of  the  disease  from 
any  other  cause. 

This  symptom  may  be  confined  to  the  upper  or  to 
the  upper  and  lower  extremities  or  it  may  effect  all 
of  the  muscles  of  the  body  so  that  one  can  feel  it  by 
placing  the  hand  upon  any  portion  of  the  patient's 
body.  It  has  been  observed  in  most  of  the  voluntary 
muscles.  Tremor  of  the  eyes  is  not  uncommon,  but 
not  nearly  so  common  as  in  the  extremities. 

It  may  be  so  severe  that  it  may  become  difficult 
for  the  patient  to  do  any  kind  of  accurate  work  with 
the  hands  or  even  to  walk  with  comfort.  The  tremor 
in  the  hands  seems  to  differ  from  that  observed  in 
paralysis  agitans  in  that  there  is  no  especial  motion 
of  the  fingers  but  rather  a  wavelike  motion  or  oscil- 
lation of  the  separate  muscle  fibres  rather  than  a 
contraction  of  any  muscle  as  a  whole.  This  condition 
is  entirely  different  from  a  condition  of  mus- 
cular  spasms    or  cramps    described  by  Mackenzie. 


DIAGNOSIS  49 

In  my   own  observation   the  tremor  has  been  ex- 
ceedingly common  in  exophthalmic  goitre  patients 
while  distinct  cramps  have  occurred  only  in  a  very 
small  proportion  of  cases.    In  quite  a  proportion  of 
patients  who  have  suffered  from  exophthalmic  goitre 
for  a  considerable  period  the  presence  of  mild  con- 
tractions reminding  one  of  incipient  chorea  may  be 
observed.    These  contractions  seem  to  affect  especi- 
ally the  head  and  sometimes  also  the  upper  ex- 
tremities.   Since  we  are  familiar  with  the  fact  that 
removal  of  all  of  the  parathyroid  glands  invariably 
results  in  tetany  some  authors  have  attributed  the 
spasmodic  contractions  just  described  to  a  diseased 
condition  of  the  parathyroid  glands.     It  has  been 
suggested   that  this   condition   of  the   parathyroid 
glands  may  be  due  to  the  effect  upon  these  glands 
exercised  by  the  pathological  thyroid  secretion  cir- 
culating in  the  blood  in  exophthalmic  goitre,  it  being 
supposed  that  these  glands  may  have  been  rendered 
incapable  of  performing  their  physiological  functions 
precisely  as   the    muscle    fibres    have    become    in- 
capacitated by  direct  contact  with  the  same  poison. 
2 — Muscular   Weakness.     In   advanced   cases   of 
exophthalmic  goitre  there  is  always  muscular  weak- 
ness. This  may  show  itself  simply  in  the  fact  that  the 
patient  becomes  fatigued  more  readily  than  normal, 
or  it  may  become  so  serious   that    the   muscles  will 
give     out    suddenly    and    the    patient    may    lose 
complete   control    of   certain  muscle   groups    unex- 
pectedly   and   may   suddenly   drop  things   held   in 
the  hand  or  it  may  affect  the  lower  extremities  so 
that  the    patient    suddenly    falls    to    the    ground 
because  his  legs  give  way.  This  condition  has  been 


50  THYROID   GIAND 

called  paraparesis.  It  may  be  only  temporary  or  it 
may  begin  in  a  mild  form  and  increase  in  severity. 
Many  patients  first  notice  this  condition  when  they 
find  that  it  is  no  longer  possible  for  them  to  change 
from  the  sitting  to  the  standing  position  without 
lifting  the  weight  of  the  body  with  the  arms.  Con- 
versely they  find  in  changing  from  the  standing  to 
the  sitting  posture  that  unless  they  steady  them- 
selves with  their  arms  they  will  suddenly  drop  down 
into  the  seat  while  they  had  expected  to  lower  the 
body  gradually. 

This  condition  must,  of  course,  not  be  confounded 
with  similar  symptoms  which  are  frequently  present 
in  patients  suffering  from  hysteria. 

This  weakness  seems  to  be  due  to  a  condition  of 
the  muscle  tissue  itself  caused  by  the  poisoning  of 
this  tissue  by  the  thyroid  secretion  in  the  blood. 

Although  this  symptom  is  usually  present  quite 
late  in  the  course  of  the  disease  still  it  has  occasionally 
been  the  first  to  attract  the  attention  of  the  physician. 

It  is  likely  that  the  same  condition  affecting  the 
muscles  of  the  orbit  has  much  to  do  with  producing 
the  symptoms  of  exophthalmos  as  well  as  the  symp- 
toms to  be  described  later  as  Graefe's,  Stell wag's 
and  Moebius  symptoms.  Since  Landstrom  has  given 
us  a  more  perfect  knowledge  of  the  muscles  of  the 
orbit  it  seems  certain  that  the  exophthalmos  is  due 
especially  to  the  weakness  of  an  unstriped  cylinder- 
formed  muscle  which  had  formerly  been  overlooked 
both  by  anatomists  and  clinicians  as  well  as  by 
pathologists. 

This  muscle  is  under  the  control  of  the  cervical 
sympathetic  plexus     The  weakness  may  be  uniform 


DIAGNOSIS  51 

throughout  the  muscles  of  the  body  or  it  may  be 
selective  affecting  only  certain  muscles,  those  in  the 
orbit  being  affected  more  often  than  any  of  the  others. 
In  rare  cases  the  muscles  of  one  side  of  the  body  may 
be  affected  alone  but  it  is  likely  that  in  these  cases 
there  are  other  definite  complications  like  cerebral 
haemorrhage  or  circumscribed  cerebral  anaemia  or  it 
may  be  due  to  hysteria. 

In  connection  with  the  symptoms  of  exophthal- 
mos it  must,  of  course,  be  borne  in  mind  that  aside 
from  weakness  in  the  muscles  which  ordinarily  keep 
the  eyeball  in  place  there  are  other  conditions  like 
engorgement  of  veins  which  aid  in  pushing  the  eye- 
balls forward. 

There  is  quite  an  opportunity  for  theorizing  con- 
cerning the  relation  of  the  weakened  condition  of 
various  groups  of  muscles  to  other  secondary  con- 
ditions. The  digestive  disturbances  may  be  ac- 
counted for  by  the  weakened  condition  of  the  muscles 
of  the  stomach  and  intestinal  walls.  The  same  ex- 
planation may  be  applied  to  the  diarrhoeas.  It  seems, 
however,  scarcely  necessary  to  discuss  all  of  these 
theories  in  the  present  work.  It  is  quite  possible 
that  the  digestive  disturbances  are  quite  as  much 
dependent  upon  the  direct  effect  which  the  thyroid 
poison  in  the  circulation  has  upon  the  glands  se- 
creting digestive  ferments  as  upon  the  condition  of 
the  muscles  of  the  alimentary  canal. 

Although  the  effects  of  this  poison  can  be  most 
readily  demonstrated  in  the  muscular  system  still 
it  is  not  at  all  likely  that  any  of  the  other  tissues  are 
less  seriously  affected,  and  it  would  consequently  not 
be  correct  were  we  to  attribute  the  effects  which  this 


52  '  THYROID    GLAND 

disease  has  upon  the  digestive  apparatus  entirely 
to  the  impaired  muscles  of  the  walls  of  stomach 
and  intestines. 

3 — Nervous  Excitability.  From  the  first  obser- 
vations to  the  present  time  the  presence  of  great 
nervous  excitability  has  been  noticed  as  one  of 
the  symptoms  almost  invariably   present  in   some 


Fig.  10.     Shows  the  same  patient  as  Fig.  9  the  enlarged   gland 
overhanging  its  base  to  a  marked  degree. 

form.  In  fact  it  was  the  presence  of  marked  nervous 
symptoms  which  caused  the  greatest  amount  of 
opposition  against  a  separate  classification  of 
this  disease,  especially  in  the  French  Academy. 
It  was  pointed  out  constantly,  that  the  most 
marked   symptoms  of    this  disease    were    identical 


DIAGNOSIS  53 

with  those  characterizing  hysteria.  At  this  point 
a  symptom  dwelt  upon  especially  by  Martin  B. 
Tinker  should  be  emphasized.  He  points  to  the 
fact  that  these  patients  frequently  complain  of  a 
symptom  which  could  readily  be  mistaken  for 
typical  globus  hystericus  and  which  has  often  even  at 
the  present  time  caused  careful  observers  to  make 
a  diagnosis  of  hysteria  in  patients  suffering  from 
unquestionable  exophthalmic  goitre. 

In  many  of  these  cases  there  may  be  but  a  very 
small  central  lobe  which  acts  in  the  form  of  a  ball 
valve  and  interferes  with  the  patient's  breathing  and 
occasionally  even  with  the  swallowing  of  food,  or  the 
lateral  lobes  may  have  prolongations  at  their  ex- 
ternal borders  which  may  be  directed  backward  and 
inward  around  the  posterior  surface  of  the  trachea, 
and  this  may  cause  a  compression  of  the  latter  tube 
and  thus  cause  difficulty  in  breathing.  Or  again,  the 
middle  lobe  may  have  an  enlargement  on  its  lower 
border  which  may  be  permanently  located  behind 
the  upper  end  of  the  sternum  or  it  may  take  this 
position  only  when  the  patient's  tissues  are  in  a  re- 
laxed condition  during  sleep.  I  have  had  one  of 
these  patients  come  to  me  with  a  diagnosis  of  cardiac 
asthma  whose  attacks  came  on  regularly  at  night 
after  the  patient  had  fallen  asleep  but  which  would 
not  occur  in  case  the  patient  would  remain  awake 
for  any  reason.  Many  of  these  patients  wander  from 
one  sanitorium  to  another  because  their  symptoms 
of  neurasthenia  or  hysteria  are  so  marked  that  the 
presence  of  exophthalmic  goitre  is  entirely  over- 
looked. 


54  THYROID    GLAND 

The  fact  that  the  disease  comes  on  so  often  to  a 
marked  degree  directly  after  some  severe  mental, 
emotional,  or  physical  strain  has  served  still  further 
to  obstruct  the  diagnosis.  It  seems,  however,  that 
we  must  agree  with  Moebius  that  this  simply  in- 
dicates an  increase  in  the  abnormal  secretion  at  a 
time  when  there  was  a  decrease  in  resistance.  Or  it 
may  mean  a  decrease  in  resistance  in  a  case  that  was 
able  to  overcome  a  slight  increase  so  long  as  there 
was  no  abnormal  strain. 

I  am  thus  explicit  at  this  point  because  it  is  here 
that  most  errors  are  made  in  diagnosis.  In  the  be- 
ginning of  the  disease  these  patients  are  especially 
likely  to  be  moody.  They  fear  something  they  cannot 
explain,  they  are  joyous  or  depressed  or  they  may 
change  from  one  of  these  conditions  to  the  other 
without  cause  and  often  without  the  ability  of 
ascribing  their  mental  or  emotional  condition  even 
to  an  imaginary  cause. 

Many  attempts  have  been  made  to  make  differ- 
ential tests  by  the  use  of  electricity  which  have  been 
exceedingly  interesting  to  those  engaged  in  this 
research  but  as  the  results  are  entirely  speculative, 
and  unreliable  from  a  practical  standpoint,  it  will 
not  be  best  to  give  them  any  space  in  this  volume. 

It  is  of  course  plain  that  there  must  be  a  marked 
increase  in  the  power  of  the  skin  as  a  conductor  in 
patients  in  whom  profuse  sweating  is  one  of  the 
marked  symptoms  but  it  can  hardly  be  considered 
of  much  value  to  make  tests  requiring  such  great 
technical  skill  to  diagnose  cases  with  symptoms  so 
pronounced  that  they  can  readily  be  recognized  with 
the  unaided  senses. 


DIAGNOSIS  55 

4 — Mental  Deficiency.  In  a  proportion  of  these 
cases  the  first  symptom  noted  is  some  form  of  mental 
deficiency.  In  some  instances  this  may  take  one 
form,  in  others  quite  the  opposite.  Some  of  these 
patients  suffer  markedly  from  melancholia  while 
others  are  in  a  constant  state  of  exhilaration,  some 
become  quiet  and  thoughtful  while  others  talk  in- 
cessantly. In  a  number  of  instances  these  patients 
first  consult  their  physicians  because  they  cannot 
live  in  peace  with  the  other  members  of  the  family. 
In  only  a  few  instances  have  I  encountered  these 
patients  with  definite  illusions  or  hallucinations  but 
it  is  likely  that  the  proportion  of  such  patients  en- 
countered in  the  neurological  practice  must  be 
much  larger  than  in  a  surgical  practice. 

It  is  of  course  important  to  bear  in  mind  that  an 
insane  person  may  acquire  exophthalmic  goitre  in- 
dependently of  his  insanity  and  vice  versa  that  a 
patient  suffering  from  exophthalmic  goitre  may  be- 
come insane  although  in  the  latter  case  one  would 
naturally  be  likely  to  consider  the  former  condition 
responsible  for  the  latter.  On  the  other  hand  in- 
sanity and  exophthalmos  may  both  be  due  to  in- 
creased intracranial  pressure  especially  if  this  is 
caused  by  the  presence  of  a  tumor. 

5 — Vertigo.  This  symptom  is  not  present  with 
any  regularity  and  it  has  appeared  to  me  to  be  due 
largely  to  the  anaemia  in  these  cases  and  also  that  in 
many  cases  what  appears  to  be  vertigo  is  in  fact 
only  a  condition  of  unsteadiness  due  to  general 
weakness  of  the  muscles  which  come  into  use  in 
locomotion. 


56 


THYROID    GLAND 


The  symptom  is  not  of  great  diagnostic  import- 
ance in  itself.  Personally,  I  have  never  encountered 
it  in  any  case  not  sufficiently  far  advanced  to  make 
a  diagnosis  possible  long  before  this  symptom  made 
its  appearance. 


Fig.  11.  Exophthalmic  goitre  with  very  prominent  exophthal- 
mos, the  eyes  protruding  nearly  to  the  point  of  dislocation.  All  lobes 
of  the  thyroid  gland  are  markedly  enlarged  especially  the  right  lobe. 
(By  the  courtesy  of  Louis  B.  Wilson.) 

6 — Graefe's  Sign.  In  the  year  1864,  v.  Graefe 
•described  a  definite  symptom  which  had  been 
described  independently  eight  years  before  by 
Desmarres  in  France  but  neither  author  seems  to 
have  known  of  the  fact  that  the  symptom  had  been  * 
recognized  by  the  other. 

The  former's  name  has  been  attached  to  this 
symptom  because  of  his  long  continued  interest 
shown  in  this  subject  resulting  in  the  publication  of 
several  excellent  articles  and  because  he  was  one  of 
the  greatest  leaders  in  his  specialty  in  his  day. 


DIAGNOSIS  57 

The  symptom  can  be  readily  recognized  even  in 
relatively  mild  cases  but  its  absence  does  not  war- 
rant a  negative  diagnosis  in  the  individual. 

In  directing  the  eye  downward,  the  lower  margin 
of  the  upper  eyelid  does  not  follow  the  line  of  vision 
normally  but  lags  behind  or  follows  in  an  irregular 
spastic  manner.  This  clear  cut  symptom  is  of  real 
value  in  making  the  diagnosis. 

It  should  always  be  elicited  when  present.  It  is 
probably  due  to  the  weakness  of  the  eye  muscles 
due  to  the  poisoning  caused  by  the  hyperthyroidism. 
Landstrom  attributes  this  symptom  also  to  the 
diseased  condition  of  the  muscle  he  has  described. 

The  same  explanation  will  apply  to  the  condition 
elicited  by  the  tests  used  to  demonstrate  Stell wag's 
sign  and  the  sign  of  Moebius,  so  it  will  not  be  neces- 
sary to  refer  to  it  again. 

Undoubtedly  there  are  differences  in  the  inherent 
conditions  of  these  various  muscles  not  only  in  dif- 
ferent individuals  but  also  between  the  various 
groups  of  muscles  in  the  same  individual  which  will 
account  for  the  variations  in  the  results  of  these 
various  tests*. 

7 — Stellwag's  Sign.  In  close  relation  to  Graefe's 
sign  we  must  place  that  first  described  by  Stellwag 
in  1869.  This  consits  in  the  fact  that  especially  in 
cases  suffering  from  marked  exophthalmos  there  is  a 
retraction  of  the  upper  eyelid  t  and  at  the  same  time 
the  lid  remains  much  more  stationary  than  it  does 
under  normal  conditions.  There  is  also  a  marked 
decrease  in  the  frequency  of  winking. 

8 — Moebius*  Sign.  In  1895,  Moebius  pointed 
out  the  fact  that  in  many  cases  of  exophthalmic 


58  THYROID   GLAND 

goitre  there  is  an  insufficiency  of  convergence.  If  the 
patient  is  directed  to  look  at  the  ceiling  and  then 
suddenly  at  his  own  nose  it  will  be  found  that  only 
one  eye  will  be  directed  toward  the  nose  and  the 
other  may  take  any  other  direction  although  it 
usually  maintains  its  axis  fairly  parallel  with  the 
eye  that  is  directed  toward  the  nose.  This  symptom 
may  also  be  elicited  by  having  the  patient  fix  an 
object  with  his  eyes  at  a  distance  of  several  yards 
then  by  gradually  approaching  the  face  a  point  will 
be  reached  at  which  only  one  eye  will  continue  to 
fix  the  object.  The  other  eye  will  cease  to  see  the 
object.  There  will  be  no  double  vision  but  the  pa- 
tient will  feel  a  certain  degree  of  strain  during  this 
experiment. 

There  is  no  definite  distance  from  the  eyes  at 
which  the  convergence  will  cease  and  the  distance  is 
not  constant  in  the  same  patient  at  different    times. 

There  does  not  seem  to  be  any  definite  relation 
between  the  degree  of  exophthalmos  and  the  de- 
ficiency indicated  by  the  test. 

This  test  is  not  positive  in  all  cases  of  exophthalmic 
goitre  but  it  can  be  elicited  in  a  majority  of  these 
cases. 

9 — Paroxysmal  Dyspnoea — Bryson's  Symptom.  In 
close  relation  also  with  the  symptoms  just  de- 
scribed we  must  place  that  of  paroxysmal  dyspnoea, 
because  it  is  undoubtedly  also  dependent  largely 
upon  the  effect  which  the  thyroid  poisoning  has  had 
upon  the  muscles  of  respiration. 

It  is  important  not  to  overlook  the  fact  that  the 
dyspnoea  may  in  reality  be  due  to  the  pressure  upon 
the  trachea  by  the  enlarged  thyroid  gland  referred 


DIAGNOSIS  59 

to  above.  Neither  must  the  anaemia  and  the  weakness 
of  the  heart  be  lost  sight  of  in  the  consideration  of 
this  subject.  It  is  likely  that  in  most  cases  all  of 
these  conditions  or  several  of  them  may  act  together, 
then  there  may  be  a  further  exacerbation  at  times 
due  to  a  dilatation  of  the  stomach  which  is  not  un- 
common and  which  would  naturally  cause  more 
disturbance  in  these  than  in  other  patients. 

Late  in  the  course  of  the  disease,  a  form  of  dysp- 
noea occurs  which  is  not.  paroxysmal  in  character 
because  it  is  entirely  due  to  the  oedema  of  the  lungs. 

10 — Intermittent  Conditions  Without  Apparent 
Exciting  Cause.  There  are  several  conditions 
which  come  and  go  intermittently  which  may  be 
considered  together.  They  may  all  occur  in  the 
same  patient  at  the  same  time  or  at  different  times, 
or  they  may  occur  but  once  or  twice  but  there  is 
this  peculiarity  that  it  does  not  seem  possible  to 
determine  a  satisfactory  exciting  cause  for  their 
occurrence. 

These  conditions  are  vomiting,  diarrhoea,  sweating 
often  over  circumscribed  portions  of  the  surface 
of  the  body,  and  mental  depression,  all  intermit- 
tent. In  many  cases  there  seems  to  be  a  general  ex- 
acerbation of  the  disease  whenever  one  or  more  of 
these  symptoms  appear. 

During  these  times  the  thyroid  gland  is  sometimes 
engorged  to  a  condition  which  has  been  aptly  com- 
pared with  a  lactating  breast  as  compared  with  the 
same  organ  during  its  inactive  stage.  That  there  is 
an  increase  in  the  local  blood  supply  during  periods 
of  exacerbation  there  can  be  no  doubt. 


60 


THYROID   GLAND 


So  far  as  the  gastrointestinal  symptoms  are  con- 
cerned it  is  likely  that  the  involuntary  muscles 
suffer  quite  as  much  in  the  walls  of  the  stomach  and 
intestines  as  do  the  heart  muscles  and  the  muscles 
in  the  extremities,  and  this  would  readily  account 
for  any  disturbances  in  this  part  of  the  body  .The 
mental  depression  has  been  attributed  to  the  direct 
effect  of  the  hyperthyroidism  upon  the  tissues  of  the 
brain. 


Fig.  12.  Exophthalmic  goitre  with  the  goitre  scarcely  percepti- 
ble but  the  exophthalmos  quite  marked  but  not  nearly  so  prominent 
as  Fig.  11.     (By  courtesy  of  Louis  B.  Wilson.) 

The  erratic  sweating  reminds  one  very  forcibly  of 
hysteria  and  this  symptom  has  frequently  been 
brought  forward  in  support  of  the  neurotic  origin 
of  the  disease.  It  seems,  however,  not  unreasonable 
to  suppose  that  notwithstanding  the  fact  that  satis- 
factory nerve  lesions  cannot  be  demonstrated  still 


DIAGNOSIS  61 

so  general  a  poison  is  likely  to  have  some  effect 
directly  upon  the  nerve  tissues  and  that  certain 
branches  will  be  more  affected  than  others.  The 
actual  pathological  findings  in  the  nervous  system 
have  been  fully  described  in  the  chapters  on  path- 
ology. In  connection  with  the  condition  of  intermit- 
tent mental  depression  without  apparent  exciting 
cause,  it  is  proper  to  refer  to  epiliptiform  seizures 
which  frequently  have  been  reported.  There  is  no 
reason  why  true  epilepsy  should  not  complicate 
exophthalmic  goitre  but  there  are  cases  in  which 
the  cortical  irritation  is  undoubtedly  directly  due 
to  the  thyroid  poison.  It  is  often  difficult  to  distin- 
guish between  these  paroxysms  and  those  due  to 
hysteria  which  also  frequently  complicates  exoph- 
thalmic goitre. 

Here  again  it  is  necessary  to  establish  the  existence 
of  exophthalmic  goitre  because  a  mistaken  diagnosis 
might  readily  give  rise  to  an  endless  amount  of 
harm  to  the  patient.  Undoubtedly,  many  cases 
diagnosed  as  hysteria  which  are  actually  suffering  from 
exophthalmic  goitre  have  been  made  much  worse 
by  extended  travel,  mountain  climbing,  social  di- 
versions, vigorous  hydrotherapeutic  treatment  or 
by  the  various  other  methods  often  employed  in 
the  treatment  of  patients  suffering  from  hysteria. 
I  have  personally  encountered  a  number  of  these  in- 
stances. 

11 — Conditions  Increasing  Gravity  of  Disease. 
A  number  of  conditions  regularly  serve  to  in- 
crease the  gravity  of  exophthalmic  goitre  some- 
times to  an  alarming  or  even  to  a  fatal  extent,  and 
it  is  consequently  important  that  these  should  be 


62  THYROID   GLAND 

pointed  out  with  especial  emphasis.  This  is  true 
especially  because  some  of  these  conditions  are  em- 
ployed in  the  treatment  of  neurasthenia  or  hysteria 
and  others  in  the  treatment  of  simple  goitre. 
'^Psychic  excitation  is  extremely  harmful.  In 
many  instances  every  symptom  is  increased  with  enor- 
mous rapidity  so  that  the  patient  loses  ground  to  a 
marked  extent  from  day  today  and  a  week  or  a  month 
may '^change  the  case  from  a  hopeful  to  a  hopeless 
condition.  I  have  repeatedly  observed  such  decline. 
It  seems  in  these  cases  as  though  the  blood  were 
rapidly  filled  with  a  most  active  poison.  Mental 
and  physical  exhaustion  bring  the  same  results  only 
in^a  less  violent  form.  In  a  number  of  cases  in  which 
the  condition  was  mistaken  for  neurasthenia  and 
consequently  treated  by  vigorous  exercise  and  mental 
diversion  and  social  excitement,  I  have  seen  these 
patients  become  worse  rapidly  only  to  improve  upon 
the  substitution  of  absolute  rest. 

In  order  to  impress  this  fact  more  acutely,  I  will 
give  an  abstract  of  the  history  of  a  case  under  treat- 
ment at  the  present  time.  A  business  man,  34  years 
of  age,  who  had  severely  overworked  for  a  number 
of  years  began  to  lose  a  pound  in  weight  each  day 
for  a  period  of  ten  weeks,  he  also  became  severely 
nervous.  Being  exceedingly  powerful  and  weighing 
240  pounds,  he  did  not  pay  much  attention  to  the 
loss  of  weight  and  strength  which  he  attributed  to 
the  fact  that  he  had  worked  from  seven  in  the  morn- 
ing until  one  o'clock  the  following  morning  during 
this  time.  When  he  began  to  suffer  from  dyspnoea 
he  consulted  his  physician  who  prescribed  a  diet, 
out-door  exercise  and  tonics,  and  a  few  weeks  later  a 


DIAGNOSIS  63 

trip  in  the  mountains  at  an  elevation  of  over  10,000 
feet  with  long  rides  on  horseback  over  mountain 
trails.  The  case  proved  on  examination  to  be  a 
typical  exophthalmic  goitre.  It  is  plain  that  the  trip 
would  have  been  extremely  harmful  if  not  worse. 

The  administration  of  thyroid  extract  is  sure 
to  have  a  harmful  influence  upon  these  patients 
although  there  may  be  a  decrease  in  the  size 
of  the  goitre.  The  decrease  in  the  size  of  the 
goitre  is  especially  likely  to  occur  in  patients 
who  have  suffered  from  simple  goitre  for  some 
time  before  the  occurrence  of  exophthalmic  goi- 
tre. Recently,  I  have  examined  a  maiden  lady 
of  thirty-six  years  who  came  for  relief  of  gas- 
tric ulcer.  She  had  carried  a  simple  goitre  for 
a  number  of  years  without  any  discomfort.  Eight 
months  ago  she  began  to  suffer  from  tachycardia 
and  at  the  same  time  her  eyes  began  to  bulge  for- 
ward. She  also  lost  rapidly  in  strength.  Two  months 
ago  she  began  to  suffer  from  intermittent  nausea, 
pain  in  the  region  of  the  stomach,  occasional  diarr- 
hoea, profuse  sweating,  dysmenorrhea.  All  of  these 
conditions  were  attributed  by  her  and  her  physician 
to  a  gastralgia  and  as  the  symptoms  were  increased, 
to  ulcer  of  the  stomach. 

The  patient  directed  the  physician's  attention  to 
the  presence  of  the  goitre,  but  the  latter  was  so 
thoroughly  engrossed  in  the  care  of  the  stomach 
that  he  gave  only  incidentally  some  slight  attention 
to  the  goitre  by  prescribing  thyroid  extract  inter- 
nally and  an  iodine  ointment  for  external  use.  Not- 
withstanding the  most  painstaking  attention  to  the 
stomach  the  patient  has  lost  over  three  pounds  each 


64  THYROID    GLAND 

week  for  the  last  eight  weeks.  She  is  now  exceed- 
ingly anaemic  and  weak,  her  pulse  beats  136  times 
per  minute  and  she  has  all  of  the  typical  symptoms 
of  exophthalmic  goitre  described  above.  This  case 
is  not  at  all  isolated.  I  simply  describe  it  because  it 
was  so  typical  in  every  respect. 

What  I  have  said  of  thyroid  extract  applies  to  a 
somewhat  slighter  extent  to  the  use  of  iodine  in  the 
treatment  of  exophthalmic  goitre.  The  use  of  iodine 
in  any  form  always  makes  them  worse. 

Emaciation  and  Anaemia.  In  advanced  cases 
emaciation  and  anaemia  are  practically  always 
present  but  it  will  hardly  be  necessary  to  discuss 
these  symptoms  because  they  are  plainly  secondary 
to  the  malnutrition  which  is  caused  by  the  condition 
of  the  gastrointestinal  tract  described  above. 

We  have  confirmed  the  findings  of  Kocher  in  the 
examination  of  the  blood  that  there  is  an  increased 
lymphocytosis  and  a  decreased  leucocytosis  but  in 
itself  the  blood  examination  cannot  determine  the 
diagnosis,  it  can  at  most  confirm  a  diagnosis  which 
has  already  been  made  from  a  study  of  the  symptoms 
described  above. 

,  Kocher  reports  careful  blood  examinations  in 
fifty-eight  cases  in  which  he  found  the  number  of 
lymphocytes  increased  while  the  polynuclear  forms 
were  diminished.  The  total  number  of  leucocytes 
was  normal  or  rather  below  normal.  The  increase  in 
lymphocytes  was  sometimes  absolute  but  more  com- 
monly relative.  In  early  cases  and  in  those  that 
have  improved  under  treatment  there  is  usually  no 
increase  of  lymphocytes. 


DIAGNOSIS  65 

Conditions  Occasionally  Present.  There  are  some 
other  conditions  which  seem  of  little  importance 
because  they  are  present  only  in  a  very  small 
proportion  of  cases,  but  as  they  are  likely  to  direct 
the  attention  of  the  physician  away  from  the  correct 
diagnosis  it  seems  proper  to  give  them  a  limited 
amount  of  space  at  this  point.  Their  presence  or 
absence  should  not  affect  the  diagnosis  of  exophthal- 
mic goitre  but  it  is  important  that  their  presence 
be  not  used  to  introduce  doubt  into  the  correctness 
of  a  positive  diagnosis. 

Discoloration  of  the  Skin.  In  some  cases  there 
is  a  marked  degree  of  darkening  of  the  skin  es- 
pecially in  the  portions  exposed  to  light  or  to  the 
irritation  of  certain  portions  of  the  clothing  like 
garters  and  waistbands. 

The  mucous  membrane  is  either  entirely  free  or 
only  very  slightly  affected.  In  the  face  the  most 
marked  portion  is  around  the  eyes. 

The  areas  about  the  nipples  and  the  axillary 
spaces,  the  lower  portion  of  the  abdomen  and  the 
inner  surface  of  the  thighs  are  usually  darker  than 
the  remaining  portion  of  the  body.  Theoretically  it 
may  be  supposed  that  this  condition  is  due  to  the 
effect  of  the  thyroid  poison  upon  the  suprarenal 
glands  which  seems  reasonable  although  it  will  re- 
quire much  careful  study  to  prove  or  disprove  this 
theory  because  it  is  not  likely  that  the  pathological 
material  can  be  obtained  in  a  sufficiently  fresh  con- 
dition in  a  considerable  number  of  these  cases  to 
bring  about  positive  results. 

The  pigmentation  changes  with  the  severity  of  the 
conditions    and    disappears    almost    entirely    after 


66 


THYROID    GLAND 


operation  if  this  treatment  has  been  successful  in  re- 
moving the  typical  symptoms  of  the  disease. 

These  patients  are  likely  to  be  mistaken  for  cases 
of    Addison's    disease.    It  is  plain  that  such  a  mis- 


Fig.  13.     Profile  of  exophthalmic  goitre  with  but  a  slight  goitre 
but  fairly  marked  exophthalmos.     (By  courtesy  of  Louis  B.  Wilson.) 

take  would  probably  prove  fatal  to  the  patient 
unless  corrected  before  the  degenerative  changes  had 
advanced  to  a  hopeless  condition. 


DIAGNOSIS  67 

There  is,  of  course,  no  reason  why  Addison's 
disease  should  not  occasionally  complicate  exoph- 
thalmic goitre,  but  one  should  always  exclude  the 
latter  disease  carefully  in  every  case  in  which  the 
presence  of  pigmentation  may  suggest  the  presence 
of  Addison's  disease  because  in  this  way  valuable 
time  for  treatment  of  the  hyperthyroidism  may  not 
be  lost.  It  is  possible  that  the  pigmentation  may  be 
due  in  these  cases  to  the  effect  of  the  thyroid  poison 
upon  the  suprarenal  glands. 

Erythema.  This  condition  although  not  com- 
mon should  be  borne  in  mind  because  it  is  likely  to 
occur  early  in  the  disease  and  thus  cause  the  physi- 
cian's attention  to  be  directed  away  from  the  correct 
diagnosis  unless  he  is  familiar  with  the  fact  that  it 
occurs  as  a  complication  of  exophthalmic  goitre. 

Blushing.  Occasionally  patients  suffering  from 
exophthalmic  goitre  are  annoyed  by  the  fact  that 
the  slightest  mental  excitement  causes  them  to 
blush  violently,  a  symptom  which  is  less  uncommon 
in  young  women  who  are  suffering  from  this  disease 
early  in  its  course  before  marked  anaemia  has  ap- 
peared. 

Urticaria.  In  some  instances  urticaria  may  occur 
either  spontaneously  or  upon  external  irritation. 
In  some  instances  only  one  form  of  irritation  will 
bring  about  this  condition  while  in  others  it  may 
be  brought  about  by  many  forms  of  external  irrita- 
tion. 

Circumscribed  Oedema.  In  a  considerable  pro- 
portion of  patients  suffering  from  exophthalmic 
goitre  circumscribed  oedema  may  be  observed.  This 
condition  may  remain  for  days  or  weeks  or  it  may 


68  THYROID    GLAND 

appear  suddenly  and  disappear  again  within  a  few 
hours.  It  may  reappear  in  the  same  location  or  at 
any  other  point  or  it  may  disappear  permanently. 
This  condition  can  be  differentiated  from  anasarca 
by  the  fact  that  it  is  not  influenced  by  the  position 
of  the  part  of  the  body  affected  and  that  its  is  not 
symmetrical. 

It  is  undoubtedly  related  in  some  way  with 
myxcedema  although  the  histological'  sections  of 
tissue  which  have  been  removed  from  these  circum- 
scribed areas  are  quite  different  from  similar  sec- 
tions made  in  cases  suffering  from  myxcedema.  The 
tissue  in  the  former  is  thickened  because  of  the  pres- 
ence of  water,  in  the  latter  because  of  the  infiltration 
with  a  mucoid  substance. 

Myxoedema  has  been  observed  in  some  cases  in 
connection  with  exophthalmic  goitre  although  the 
presence  of  this  condition  would  indicate  an  absence 
of  activity  of  the  thyroid  gland  while  as  has 
been  repeatedly  stated  exophthalmic  goitre  repre- 
sents an  increase  in  thyroid  activity.  This  apparent 
discrepancy  in  theories  has  been  explained  by  the 
supposition  that  on  the  one  hand  the  thyroid  gland 
has  lost  its  ability  to  perform  its  normal  physiological 
function,  while  on  the  other  hand  a  portion  of  the 
gland  is  still  active  in  producing  abnormal  secretion 
which  when  forced  into  the  circulation  gives  rise  to 
more  or  less  typical  exophthalmic  goitre.  It  is  most 
important  to  bear  in  mind  these  conditions  because 
this  will  enable  the  physician  to  recommend  treat- 
ment which  is  likely  to  correct  both  conditions.  The 
treatment  indicated  for  the  relief  of  exophthalmic 
goitre  in  these  cases  must  consist  in  the  removal  of 


DIAGNOSIS 


69 


that  portion  of  the  thyroid  gland  containing  the 
nodules  secreting  the  substance  which  causes  the 
disease,  or  the  double  ligation  and  section  of  the 
superior,  inferior,  and  anterior  thyroid  veins. 
Then  the  myxcedema  must  be  relieved  by  adminis- 
tering thyroid  extract.     Were  the  thyroid  extract 


Fig.  14.     Exophthalmic  goitre,  very  early  stage,  neither  the  goitre 
nor  exophthalmos  well  marked.     (By  courtesy  of  Louis  B.  Wilson.) 

administered  before  the  removal  of  the  diseased 
portion  of  the  thyroid  gland,  the  tachycardia  and 
the  other  symptoms  of  exophthalmic  goitre  would 
increase  probably  to  a  fatal  extent.  On  the  other 
hand  were  the  thyroid  gland  removed  without  the 


70  THYROID    GLAND 

subsequent  use  of  thyroid  extract,  there  would  un- 
doubtedly result  an  increase  in  the  severity  of  the 
myxcedema.  In  these  cases  it  would  be  reasonable 
to  remove  the  diseased  thyroid  gland  and  simul- 
taneously transplant  normal  thyroid  gland  from 
another  person. 

Scleroderma.  This  condition  has  frequently  been 
observed.  Singer  believes  that  there  is  a  definite 
relation  between  the  condition  of  the  thyroid  gland 
and  scleroderma  not  only  in  cases  in  which  it  has 
been  incidentally  observed  in  connection  with  goitre 
but  also  in  all  cases  in  which  the  patient  is  suffering 
from  scleroderma  independently. 

Alopecia.  In  a  number  of  cases,  either  circum- 
scribed or  general,  baldness  has  occurred  as  a  com- 
plication of  exophthalmic  goitre  and  in  other  cases 
there  has  been  a  loss  of  eyebrows,  eyelashes,  axillary 
and  pubic,  hair.  The  beard  seems  affected  less  fre- 
quently than  other  portions  of  the  body. 

Atrophy  of  the  Mammary  Glands.  There  seems 
to  be  a  marked  shrinkage  of  the  mammary  glands 
early  in  the  course  of  exophthalmic  goitre  before 
the  effect  upon  the  patient's  general  condition  is 
sufficient  to  produce  so  marked  a  local  effect.  This 
seems  to  be  coincident  with  a  depression  in  the 
sexual  vigor  of  these  patients.  This  condition  does 
not  preclude  pregnancy,  although  it  is  much 
more  common  to  encounter  patients  in  whom  ex- 
ophthalmic goitre  has  developed  during  the  period 
of  pregnancy  or  lactation  than  those  in  whom  preg- 
nancy has  occurred  during  the  existence  of  exoph- 
thalmic goitre. 


DIAGNOSIS  71 

A  circumscribed  oedema  of  one  or  both  breasts 
may  be  mistaken  for  a  hypertrophy  but  the  condition 
is  the  same  as  though  it  occurred  in  any  other  portion 
of  the  body. 

Enlargement  of  Lymph  Nodes.  In  operating  for 
the  removal  of  portions  of  the  thyroid  gland  one 
frequently  encounters  enlarged  lymph  nodes.  It  is 
doubtful  if  these  have  any  definite  relation  to  the 
disease.  It  is  important  not  to  mistake  them  for 
parathyroid  glands.  Confounding  them  with  aberrant 
thyroid  glands  is  of  no  importance  because  the  re- 
moval of  the  latter  is  immaterial. 

Enlargement  of  Thymus  Gland.  Practically,  the 
fact  is  important  that  this  gland  is  enlarged  in 
a  considerable  proportion  of  cases.  At  autopsies 
in  patients  succumbing  to  exophthalmic  goitre 
the  upper  margin  of  the  thymus  gland  has  fre- 
quently been  found  to  touch  the  lower  end  of  the 
thyroid,  or  in  other  instances  enlarged  lymph  nodes 
have  been  found  between  the  two.  In  the  cases  that 
died  after  thyroidectomy  Capelle  found  persistency 
of  the  thymus  gland  in  79  per  cent.  It  is  possible 
that  there  is  a  lower  death  rate  in  cases  in  which 
the  thymus  gland  has  disappeared  because  in  sta- 
tistics taken  without  reference  to  operative  treat- 
ment the  number  of  persistent  thymus  glands  is 
always  considerably  lower.  Von  Houseman  found  a 
persistent  thymus  in  each  of  four  out  of  eight  cases. 
If  this  theory  should  become  established,  it  would  of 
course  become  necessary  to  find  some  way  of  de- 
termining the  presence  or  absence  of  a  persistent 
thymus  gland  before  undertaking  the  operation. 


72  THYROID    GLAND 

In  its  presence  it  would  then  become  proper  to 
make  the  operation  according  to  a  plan  which  will 
be  described  fully  under  surgical  treatment  which 
would  materially  reduce  the  severity  of  the  opera- 
tion, possibly  at  the  risk  of  being  less  uniformly 
effective.  This  would  have  a  tendency  to  leave  a 
safe  margin  of  resistance  in  this  particular  class  of 
cases. 

Osteomalacia.  This  condition  is  mentioned  by 
many  authors  all  of  whom  seem  to  be  convinced  that 
there  is  some  relation  between  it  and  thyroid  dis- 
ease. Clinically  I  cannot  discuss  this  condition  from 
personal  observation.  This  may  be  a  coincidence  or  it 
may  indicate  that  the  condition  is  quite  as  rare  in 
those  suffering  from  exophthalmic  goitre  as  it  is  in 
others  or  the  condition  of  the  bones  may  not  have 
been  determined  with  a  sufficient  degree  of  accuracy 
in  my  cases. 

In  a  number  of  cases  of  fracture  in  which  union 
failed  to  take  place  promptly  we  have  administered 
thyroid  extract  but  it  is  impossible  to  determine 
positively  whether  this  remedy  definitely  influenced 
the  healing  of  these  fractures. 

General  Appearance  of  Patients  Suffering  from 
Exophthalmic  Goitre.  Patients  suffering  from  sim- 
ple goitre  need  not  be  especially  described  because 
the  condition  is  so  apparent  that  it  will  require 
no  especial  description  to  enable  even  the  least 
experienced  physician  to  recognize  the  condition. 
The  following  illustrations,  Fig.  7  and  Fig.  8,  will 
be  introduced  simply  for  the  purpose  of  com- 
parison. As  regards  the  size  of  the  swelling,  it  may 
be  so  small  as  to  be   scarcely    perceptible  and   it 


DIAGNOSIS  73 

may  be  necessary  to  palpate  the  neck  in  order  to 
discover  any  abnormal  condition  or  again  in  case 
the  growth  is  retrosternal  it  may  become  necessary 
to  have  the  patient  go  through  the  act  of  swallow- 
ing in  order  to  make  the  enlargement  apparent 
when  it  rises  with  the  remaining  portions  of  the 
thyroid  gland  which  may  not  be  enlarged. 

From  this  size  it  may  vary  in  other  cases  to  an 
enormous  proportion.  Fig.  9  and  Fig.  10  illustrate 
one  of  these  cases  in  which  the  gland  when  removed 
weighed  six  pounds  and  fourteen  ounces  after  the 
blood  had  drained  away. 

The  growth  may  be  sessile  with  a  broad  base  as 
shown  in  Fig.  9  or  it  may  be  narrower  at  the  base 
with  its  greatest  portion  projecting  down  over  the 
chest,  or  it  may  arise  from  one  lobe  and  be  pedun- 
culated. In  fact  the  swelling  may  take  upon  itself 
a  large  variety  of  forms  and  the  size  may  vary 
enormously.  It  is  surprising  how  large  a  goitre  a 
patient  will  occasionally  carry  about  without  seek- 
ing relief  from  surgical  interference.  This  was  true 
especially  in  the  portions  of  Switzerland  in  which 
goitres  are  endemic  before  Kocher  popularized  the 
operation  of  thyroidectomy.  In  some  instances  the 
growth  becomes  so  large  that  the  patient  has  to 
improvise  a  form  of  bandage  which  contains  a 
pouch  in  front  into  which  the  goitre  fits  and  a  broad 
band  behind  to  be  buttoned  around  the  neck  so 
that  the  weight  of  the  tumor  is  supported  partly 
from  the  back  of  the  neck  instead  of  pulling  entirely 
on  the  front.  Fortunately  for  the  patients  the  old 
fear  of  operation  no  longer  exists  and  consequently 


74  THYROID    GLAND 

relief  is  usually  obtained  before  so  advanced  a  con- 
dition has  developed. 

In  exophthalmic  goitre  the  size  of  the  goitre  is 
rarely  an  important  feature  although  occasionally 
one  encounters  large  goitres  in  connection  with  this 
disease.  The  striking  feature  in  the  appearance  of 
these  patients  is  the  prominence  of  the  eyes  which 
may  vary  from  a  scarcely  perceptible  prominence  to 
an  actual  protrusion  which  may  be  so  marked  that 


Fig.  15.     Exophthalmic  goitre.     The  exophthalmos  and  the  goi- 
tre  well  marked.      (By  courtesy  of  Louis  B.  Wilson.) 

the   eyeball    may   actually   be   dislocated   from   its 
socket  so  that  it  hangs  down  upon  the  cheek. 

I  have  personally  encountered  but  one  case  in 
which  the  condition  was  so  extreme  but  many  cases 
have  been  reported  and  I  have  encountered  a  num- 
ber of  cases  that  approached  this  condition.     Fig. 


DIAGNOSIS  75 

11  approaches  this  degree  of  protrusion.  In  this 
case  the  goitre  itself  is  of  considerable  size  while  in 
Fig.  12  we  have  quite  a.  marked  protrusion  of  the 
eyes  while  the  enlargement  of  the  thyroid  is  scarcely 
perceptible  from  a  distance.  The  same  is  true  in 
Fig.  13  in   which   the  condition  is  shown  in  profile. 

.Figures  14,  15,  16,  show  various  degrees  of  pro- 
trusion but  in  cases  like  these  there  is  no  difficulty 
in  recognizing  the  condition.  It  is  in  cases  like  the 
one  shown  in  Fig.  17  in  which  neither  the  exoph- 
thalmos nor  the  goitre  is  prominent  that  the  con- 
dition is  likely  to  be  overlooked. 

Complications.  Aside  from  the  complications 
which  have  been  mentioned  in  connection  with  the 
discussion  of  the  major,  minor,  and  incidental 
symptoms  exophthalmic  goitre  may  be  complicated 
with  all  diseases  which  a  person  can  acquire  who  is 
not  suffering  from  the  condition  and  conversely 
aside  from  the  fact  that  a  patient  with  slight  re- 
sistance is  more  likely  to  suffer  from  diseases  in 
general,  it  may  be  said  that  a  patient  suffering  from 
exophthalmic  goitre  is  no  more  likely  to  suffer  from 
any  complication  than  any  normal  person. 

Contagious  and  infectious  diseases  have  not  been 
mentioned  frequently  in  connection  with  this  disease 
but  this  may  be  accounted  for  by  the  fact  that  these 
patients  are  not  likely  to  be  exposed  to  contagion 
or  infection.  An  exception  should  be  noted  in  the 
fact  that  relatively  a  considerable  number  of  these 
cases  suffer  from  tuberculosis. 

.  All  other  diseases  have  been  mentioned  but  it  is 
clearly  not  necessary  to  enumerate  these  separately. 


76  THYROID    GLAND 

It  is,  however,  exceedingly  important  to  bear  in 
mind  the  fact  that  the  presence  of  any  other  disease 
does  not  exclude  the  possibility  of  its  complication 
with  exophthalmic  goitre  and  also  that  this  is  a 
grave  complication  at  all  times  and  one  that  will 
require  especial  attention.  An  example  of  the  im- 
portance of  this  element  will  become  apparent  upon 
studying  the  report  of  Gautiers,  of  Geneva,  who 
found  that  symptoms  of  exophthalmic  goitre  fre- 
quently develop  in  apparently  latent  cases  upon  the 
administration  of  iodide  of  potassium.  The  use  of 
this  drug  is  of  course  especially  contraindicated  to- 
gether with  the  use  of  thyroid  extract  in  cases  which 
were  suffering  primarily  from  simple  goitre  but  in 
whom  exophthalmic  goitre  developed  later. 


CHAPTER  IV. 


NON-SURGICAL  TREATMENT. 


Treatment  of  Simple  Goitre.  Although  this  book 
should  properly  not  reach  beyond  the  surgical 
side  of  this  question,  it  seems  important  to  bear  in 
mind  that  all  forms  of  non -traumatic  and  non- 
malignant  diseases  of  the  thyroid  gland  are  primarily 
medical. 

There  is  so  convenient  an  opportunity  for  the 
surgeon  of  falling  into  an  error  in  logic  at  this  point 
because  he  comes  in  constant  contact  only  with  those 
cases  that  have  failed  to  respond  to  internal  treat- 
ment that  it  may  appear  to  him  from  his  own  ex- 
perience that  internal  treatment  always  fails  to 
cure  goitre  because  it  has  always  failed  in  all  of  the 
cases  that  have  come  under  his  professional  care. 
As  a  matter  of  fact,  a  much  larger  proportion  of 
cases  never  consult  a  surgeon  because  they  recover 
spontaneously  or  they  are  cured  by  internal,  dietetic, 
and  hygienic  treatment.  For  this  reason  it  seems 
important  to  give  some  attention  to  this  feature  be- 
fore directing  attention  to  the  means  offered  by 
surgery  for  the  relief  of  thyroid  disease: 

The  fact  that  practically  all  cases  which  come  to 
the  surgeon  for  relief  of  thyroid  disease  have  wasted 
much  time  by  subjecting  themselves  to  the  ineffec- 
tive efforts  of  the  internist,  neurologist  or  the  various 
electrical  and  other  specialists  might  readily  be  con- 


78  THYROID    GLAND 

strued  to  mean  that  all  of  these  methods  are  useless 
and  that  the  patients  should  be  at  once  referred  to 
the  surgeon  for  operative  treatment.  This  conclusion 
would,  however,  be  quite  as  wrong  as  it  would  be 
for  an  internist  to  conclude  that  because  the  few 
cases  he  has  referred  to  a  surgeon  have  died  follow- 
ing the  operation,  therefore  surgical  treatment  is 
always  contraindicated. 

The  facts  are  as  follows:  More  than  one-half  of 
all  cases  of  goitre  will  recover  under  careful  dietetic, 
hygienic  and  medicinal  treatment  which  must  consist 
in  drinking  an  abundance  of  good  water  which  can 
always  be  obtained  in  regions  where  goitre  is  ende- 
mic by  distilling  it,  by  carefully  regulating  the  diet, 
by  correcting  the  conditions  of  ventilation  in  homes 
and  especially  in  sleeping  rooms,  by  insisting  upon 
an  abundance  of  sleep  and  upon  an  absence  of  ex- 
citement and  of  mental  and  of  physical  fatigue. 

So  far  the  treatment  refers  as  well  to  simple  as  to 
exophthalmic  goitre. 

In  simple  goitre  the  application  of  a  non-irritating 
absorbable  iodine  ointment  to  the  neck  seems  to  be 
of  considerable  benefit.  Internally  general  tonics 
are  of  undoubted  value  and  from  3  to  5  grains  of  a 
reliable  thyroid  extract  given  from  three  to  six  times 
daily  seems  to  have  a  specific  value. 

It  should  be  borne  in  mind  that  many  of  the 
preparations  of  the  thyroid  gland  in  the  market  are 
perfectly  inert  because  these  have  been  deprived  of 
their  active  elements  by  some  faulty  process  in  the 
manufacture.  It  is  consequently  important  to  use 
only  tested  products. 


NON-SURGICAL    TREATMENT  79 

In  case  of  simple  goitres  that  do  not  yield  upon  the 
treatment  just  outlined  it  is  well  to  inject  directly 
into  the  substance  of  the  gland  ninety  drops  of  a 
five  per  cent,  aqueous  solution  of  pure  carbolic  acid, 
a  method  introduced  and  practiced  for  many  years 
by  Professor  Moses  Gunn.  It  is  important  to  pre- 
pare this  solution  carefully  by  mixing  the  carbohc 
acid  with  boiling  water  because  when  mixed  with 
cold  water  small  globules  of  the  strong  acid  may 
continue  to  float  in  the  solution  and  these  will  cau- 
terize the  tissues  with  which  they  come  in  contact. 
This  treatment  is  to  be  repeated  once  each  week. 
When  more  than  one  lobe  of  the  gland  is  involved 
the  different  lobes  should  be  injected  at  successive 
treatments,  until  all  of  them  have  been  so  treated 
when  two  or  three  of  the  lobes  may  be  injected  at 
each  treatment.  If  the  patient  shows  marked  vertigo 
or  if  the  urine  becomes  dark  and  cloudy  the  quantity 
injected  shpuld  be  reduced.  It  is,  however,  but  rarely 
necessary  to  reduce  the  quantity.  In  order  to  deter- 
mine the  fact  that  the  injection  is  actually  made  into 
the  gland,  the  patient  should  go  through  the  effort 
of  swallowing  before  the  contents  of  the  syringe  has 
been  discharged  after  the  needle  has  been  plunged 
into  the  enlarged  gland. ,  If  the  needle  is  in  the  proper 
position  the  syringe  will  rise  with  the  act  of  swallow- 
ing. It  is  well  for  the  patient  to  lie  down  for  a  few 
moments  after  the  injection  has  been  made  because 
there  is  frequently  a  little  vertigo  directly  after  the 
solution  has  been  injected  into  the  gland.  During 
the  administration  of  many  hundreds  of  these  in- 
jections, I  have  never  seen  any  harmful  effects. 


80  THYROID    GLAND 

In  cases  which  can  be  cured  by  this  method,  there 
is  usually  a  marked  improvement  by  the  time  the 
patient  has  received  from  six  to  ten  injections.  In 
the  meantime  the  treatment  with  tonics,  thyroid 
extract  and  hygienic  and  dietetic  methods  should  be 
continued.  In  many  cases  in  which  the  latter  treat- 
ment alone  without  the  injections  made  no  impres- 
sion  the   patients   have   recovered   fully   after  this 


Fig.  16.  Exophthalmic  goitre.  Both  exophthalmos  and  goitre 
are  sufficiently  advanced  to  be  easily  recognizable  but  cases  of  this 
degree  are  very  frequently  overlooked. 

treatment  was  added.  It  seems  important  to  insist 
upon  the  use  of  distilled  or  pure  spring  water  in  all 
patients  who  continue  to  live  in  the  vicinity  in  which 
they  acquired  the  goitre. 

In  simple  goitre  in  regions  where  this  disease  is 
not  endemic  fully  fifty  per  cent,  of  all  cases  will  re- 


NON-SURGICAL    TREATMENT  81 

cover  by  the  use  of  hygienic,  dietetic  and  medicinal 
treatment  and  more  than  one-half  of  the  remaining 
cases  will  recover  if  the  injection  treatment  is  added 
to  the  other  treatment.  The  remaining  twenty-five 
per  cent,  will  resist  every  form  of  treatment  except 
excision  which  will  be  considered  later.  In  countries 
where  goitre  is  endemic  these  methods  seem  less 
useful  probably  because  it  is  so  much  more  difficult 
to  eliminate  the  exciting  cause.  Electricity  has  been 
employed  in  the  form  of  x-ray  exposure  and  by  the 
application  of  practically  every  form  of  this  agent, 
Undoubted  improvement  has  been  noted  in  patients 
subjected  to  this  form  of  treatment  but  it  is  diffi- 
cult to  determine  just  how  much  can  properly  be 
attributed  to  the  action  of  the  electricity  and  how 
much  should  be  attributed  to  the  benefits  from 
concurrent  diet,  hygiene  and  medication. 

The  cases  that  do  not  yield  to  any  of  these  forms 
of  treatment  should  then  properly  be  considered 
surgical  in  character  and  should  receive  relief  through 
operative  interference  provided  the  patient  suffers 
because  of  the  presence  of  the  deformity  or  because 
of  obstruction  to  breathing  or  swallowing  or  discom- 
fort from  pressure  either  because  of  the  location  or 
the  size  of  the  goitre. 

That  there  is  a  certain  proportion  of  cases  of  simple 
goitre  which  will  not  yield  to  any  form  of  non- 
surgical treatment  there  can  be  no  doubt  and  it  is 
this  class  of  cases  that  come  under  the  observation 
of  the  surgeon,  after  all  other  means  have  been  tried 
and  which  gives  him  the  impression  that  none  but 
surgical  treatment  is  indicated  for  the  relief  of 
patients  suffering  from  goitre  unless  he  is  in  a  po- 


82  THYROID    GIvAND 

sition  to  observe  the  much  larger  proportion  of  cases 
also  which  never  come  to  his  department  because 
non-surgical  treatment  has  eliminated  them.  The 
varieties  of  non-exophthalmic  goitres  which  are  most 
likely  to  yield  to  non-surgical  treatment  will  be  con- 
sidered further  with  the  discussion  of  the  pathology 
of  goitre. 

The  reason  for  discussing  the  medical  treatment  so 
briefly  is  of  course  apparent  but  I  wish  to  be  em- 
phatic in  stating  that  all  non-malignant  and  non- 
traumatic diseases  of  the  thyroid  gland  should  first 
be  considered  medically  because  with  the  rise  of 
thyroid  surgery  it  would  otherwise  be  certain  that 
many  patients  would  be  subjected  to  operative  treat- 
ment quite  unnecessarily.  More  than  one-half  of  all  the 
patients  who  have  come  to  me  for  examination  dur- 
ing the  past  twenty  years  have  recovered  promptly 
upon  the  use  of  non-surgical  treatment  and  the 
proportion  of  cases  that  are  curable  without  opera- 
tion coming  to  the  surgeon  for  advice  must  neces- 
sarily be  much  smaller  than  that  coming  to  the 
internist  for  the  same  purpose.  It  is  doubtful  whether 
one  could  come  upon  some  permanency  of  cure  fol- 
lowing the  non-surgical  treatment  of  these  cases  in 
countries  where  goitre  is  endemic. 

That  the  results  of  non-surgical  treatment  are 
permanent  where  they  are  primarily  effective  in 
this  vicinity,  I  have  had  an  abundance  of  opportunity 
to  confirm,  because  I  had  the  care  of  many  of  these 
cases  while  serving  as  the  assistant  of  Prof.  Moses 
Gunn,  who  introduced  the  carbolic  acid  treatment, 
and  I  have  followed  many  of  these  cases  for  a  period 
of  twenty-five  years.    It  would  be  interesting  to  fol- 


NON-SURGICAL    TREATMENT  83 

low  these  cases  statistically  in  some  of  the  great  in- 
ternal clinics  but  I  have  failed  to  encounter  any 
important  records.  It  seems  that  no  one  has  followed 
these  cases  after  their  recovery  for  the  purpose  of 
reliable  statistics  to  compare  with  the  results  ob- 
tained in  cases  treated  surgically. 

Non-Surgical  Treatment  of  Exophthalmic  Goitre. 
The  use  of  rest  especially  as  well  as  other  hygienic 
and  dietetic  measures  applies  even  to  a  greater 
extent  to  the  non-surgical  treatment  of  exoph- 
thalmic goitre  than  to  the  treatment  of  simple 
goitre.  There  are,  however,  two  very  distinct  differ- 
ences. It  is  far  more  important  that  these  cases  be 
subjected  to  early  surgical  treatment  in  case  the  non- 
surgical treatment  proves  futile  than  is  the  case 
with  simple  goitre.  In  exophthalmic  goitre  prolonged 
non-surgical  treatment  in  cases  in  which  there  is  no 
improvement  always  results  in  serious  degenerative 
changes.  These  progress  to  a  point  at  which  surgical 
treatment  is  no  longer  possible  because  the  patient's 
power  of  resistance  has  been  dissipated  to  a  hopeless 
degree  so  that  a  fatal  result  must  be  expected  after 
an  operation .  Or  the  patient  may  still  have  a  sufficient 
degree  of  resistance  to  recover  from  the  operation 
which  may  serve  to  stop  the  progress  of  the  disease 
so  that  there  is  no  further  degeneration  of  any  of 
the  tissues  which  suffered  as  a  result  of  the  thyroid 
poisoning  before  the  operation,  but  the  degree  of 
degeneration  may  have  advanced  so  far  that  the 
power  of  recuperation  may  be  entirely  or  almost 
entirely  lost.  Such  cases  may  continue  to  live  for 
many  years  following  the  removal  of  the  diseased 
gland    without    any    increase    in    symptoms    which 


84  Thyroid  gland 

would  indicate  that  the  thyroid  poisoning  is  still 
active  but  they  will  remain  weak.  If  they  are  de- 
pendent upon  their  own  efforts  for  their  support 
they  invariably  become  public  charges.  If  they  have 
independent  means  they  are  usually  extremely  un- 
happy because  they  are  not  able  to  follow  the  pur- 
suits or  pleasures  which  they  enjoyed  during  their 
lives  before  acquiring  exophthalmic  goitre.  Even  if 
surgical  treatment  is  employed  early  there  is  usually 
not  a  complete  recovery  according  to  the  investiga- 


I 


Fig.  17.  Represents  a  case  of  exophthalmic  goitre  in  which 
both  the  exophthalmos  and  the  goitre  are  so  slight  that  they  will  usually 
not  be  discovered  until  the  diagnosis  is  suggested  by  the  presence  of 
other  symptoms  like  tachycardia,  tremor  or  muscular  weakness. 

tions  of  Landstrdm.  Although  the  patients  may  be 
apparently  quite  well  a  careful  examination  of  the 
heart  will  usually  demonstrate  at  least  a  slight 
defect. 

Treatment.  Rest  is  the  most  important  element 
in  the  treatment  of  exophthalmic  goitre  and  in  the 
after-treatment  following  operations,  and  it  should 


NON-SURGICAL    TREATMENT  85 

be  borne  in  mind  that  this  refers  quite  as  much  to 
mental  and  emotional  as  to  physical  rest. 

The  mental  condition  of  these  patients  often 
causes  them  to  become  intensely  interested  in  social 
or  religious  affairs  or  in  other  matters  such  as  litera- 
ture or  music.  I  have  encountered  an  instance  in 
which  the  patient,  a  delicate  woman,  became  almost 
insanely  interested  in  card  playing.  The  particular 
subject  in  which  these  patients  waste  their  energies 
is  probably  largely  accidental  and  due  to  environ- 
ment but  it  is  equally  harmful  and  must  be  stopped 
without  making  too  severe  an  impression  upon  the 
patient's  emotions.  In  post  operative  cases  this  is 
plainly  much  easier  of  accomplishment  than  in  cases 
that  have  not  been  operated.  That  it  is  of  the  very 
greatest  importance  to  secure  rest  for  these  patients 
there  can,  however,  be  no  doubt.  This  must  be  in- 
sisted upon  for  many  months  after  the  patient  has 
apparently  recovered  without  regard  to  the  mode  of 
treatment  that  has  been  employed  in  any  given  case. 

Such  patients  should  be  guarded  as  much  as 
possible  against  severe  sudden  or  continued  strains 
that  can  be  avoided  but  that  must  be  accepted  in 
the  life  of  other  persons.  This  would  apply  especially 
to  pregnancy  which  has  resulted  in  a  large  propor- 
tion of  abortions  according  to  Schmauch  and  in  the 
death  of  a  considerable  number  of  mothers,  although 
according  to  Charcot,  the  surviving  mothers  are 
likely  to  recover  from  the  exophthalmic  goitre. 

Specific  Medication.  In  a  condition  which  is 
clearly  due  to  a  definite  poison  circulating  in  the 
blood,  the  treatment  must  logically  consist  either 
in  removing  the  source  of  the  poison,  thyroidectomy, 


86  THYROID    GLAND 

or  in  the  introduction  of  some  medium  which  will 
make  this  poison  harmless  after  it  has  been  intro- 
duced. A  number  of  attempts  have  been  made  to 
find  a  substance  which  will  have  a  neutralizing  effect 
upon  this  poison.  Moebius  has  introduced  the  serum 
of  thyroidectomized  goats  known  as  "antithyroidin," 
which  is  administered  internally  in  doses  of  from  20 
to  60  drops  every  eight  to  twelve  hours  at  first  reg- 
ularly and  later  at  intervals  of  several  days.  Much 
stress  has  been  laid  upon  giving  a  meat  free  diet  con- 
sisting mainly  of  vegetables,  fruits,  eggs  and  milk 
and  that  the  use  of  table  salt  be  reduced  to  a  minimum. 

Beebe  and  Rogers  have  prepared  and  administered 
a  serum  which  in  early  cases  has  given  good  results 
when  used  in  connection  with  rest,  hygiene  and 
proper  diet.  This  serum  seems  to  be  of  especially 
great  value  in  acute  cases  with  very  severe  symptoms. 

Forschheimer  highly  recommends  the  use  of  hydro- 
br ornate  of  quinia  in  doses  of  five  grains,  administered 
four  times  daily  in  gelatine  coated  pills,  either  with 
or  without  the  addition  of  one  grain  of  ergotin.  He 
has  usually  observed  improvement  within  48  hours 
after  beginning  this  treatment,  which  he  continues 
until  the  patient  is  normal.  He  has  observed  cures 
within  three  months  from  the  beginning  of  the  treat- 
ment while  in  one  case  he  continued  the  treatment 
uninterruptedly  for  a  period  of  three  years.  The 
patient  recovered  without  experiencing  any  harmful 
effects  from  the  use  of  the  remedy.  In  case  a  patient 
does  not  improve  from  the  use  of  the  quinine  hydro- 
bromate  in  forty-eight  hours  he  adds  one  grain  of 
ergotin  to  each  dose. 


NON-SURGICAL    TREATMENT  87 

He  has  observed  the  following  effects  of  this  treat- 
ment: 1.  The  tachycardia  disappears.  2.  The 
thyroid  gland  diminishes  in  size.  3.  The  tremor  and 
the  exophthalmos  diminishes  and  later  disappears. 
The  first  change  usually  takes  place  within  48  hours 
after  beginning  the  treatment  which  must  be  con- 
tinued until  all  symptoms  have  disappeared.  In 
nine  out  of  twelve  patients  of  fully  developed  cases 
the  treatment  was  entirely  successful,  the  failures 
were  in  the  very  violent  forms  primarily  or  in  f oud- 
royant  relapsing  cases.  In  forty-five  cases  of  all 
varieties  of  severity  treated  by  this  method  there 
were  five  failures. 

A  large  number  of  other  drugs  have  been  recom- 
mended and  discarded  which  cannot  be  discussed. 
Kocher  has  used  sodium  phosphate  with  the  hope 
of  stimulating  elimination. 

It  seems  reasonable  to  hope  that  at  some  time  a 
remedy  may  be  introduced  which  will  thoroughly 
neutralize  the  thyroid  poison  in  the  blood.  It  is 
possible  that  in  favorable  cases  this  is  accomplished 
by  the  hydrobromate  of  quinia. 

In  the  meantime  it  will  be  necessary  to  remove  the 
cause  in  a  large  proportion  of  these  cases  by  perform- 
ing thyroidectomy. 

Iodine.  For  many  years  the  internal  and  external 
use  of  various  forms  of  iodine  as  well  as  the  hypo- 
dermic injections  into  the  enlarged  thyroid  gland  in 
simple  hypertrophy  has  obtained  so  fixed  a  position 
in  the  minds  of  practitioners  of  medicine  that  it  has 
been  difficult  to  impress  upon  them  the  fact  that  in 
exophthalmic  goitre  this  remedy  is  almost  always 
certain  to  do  harm  although  it  may  cause  the  goitre 


88  THYROID    GLAND 

to  decrease  in  size.  The  manner  in  which  patients 
become  worse  is  by  an  increase  of  the  hyperthyroid- 
ism and  with  this  the  increase  in  all  of  the  important 
symptoms  of  exophthalmic  goitre  but  especially  the 
heart  symptoms. 

Lanz,  and  many  of  his  followers,  have  claimed 
constant  improvement  in  patients  who  lived  largely 
on  milk  from  thyroidectomized  goats.  This  would 
virtually  represent  another  form  of  serum  therapy. 
Many  other  observers  have  reported  improvement 
from  the  use  of  a  liberal  diet  of  milk  either  alone  or 
with  other  food. 

Thymus  gland  has  been  given  in  the  hope  of  ob- 
taining in  this  manner  a  kind  of  antibody.  The  re- 
sults do  not  seem  to  have  been  encouraging. 

Strophanthus,  belladonna  and  arsenic  are  mention- 
ed by  most  authors  but  discredited  by  more.  Re- 
liable statistics  are  lacking  with  all  of  these. 

Thyroidectomy.  General  Considerations:  Within 
a  quarter  of  a  century  this  operation  has  changed 
its  position  entirely  in  the  minds  of  the  surgical  pro- 
fession. At  the  beginning  of  this  period,  it  was  looked 
upon  as  one  of  the  most  dangerous  of  all  major  oper- 
ations and  at  the  end  of  this  short  space  of  time,  we 
look  upon  it  as  one  of  the  safest  of  major  operations. 
This  change  is  due  largely  to  the  skill  and  genius  of 
Professor  Kocher  whose  enormous  experience  en- 
abled him  early  to  speak  with  authority  upon  this 
subject,  pointing  out  methods,  recognizing  dangers, 
simplifying  technic  and  in  thyroidectonry  for  ex- 
ophthalmic goitre  pointing  out  the  importance  of 
operations  in  repeated  stages  doing  at  any  one  time 


NON-SURGICAL    TREATMENT  89 

only  as  much  as  the  individual  patient  under  con- 
sideration could  safely  bear. 

His  views  have  been  supported  on  all  sides  by 
surgeons  whose  wide  experience  has  insured  excel- 
lent surgical  judgment. 

Dangers  of  Thyroidectomy.  The  following  dan- 
gers of  thyroidectomy  should  not  be  overlooked 
1,  anesthesia;  2,  shock;  3,  haemorrhage;  4,  hyper- 
thyroidism; 5,  infection;  6,  recurrent  laryngeal  nerve 
injury;  7,  injury  to  parathyroid  glands;  8,  air  em- 
bolism; 9,  collapse  of  trachea  and  consequent  as- 
phyxia. 


CHAPTER  V. 


ANAESTHESIA. 


Accidents  from  anaesthesia  have  not  been 
uncommon  during  operations  upon  the  thyroid 
gland.  There  are  several  reasons  why  this  should 
be  the  case.  In  many  of  these  cases  respiration 
has  been  impaired  for  a  considerable  period  of 
time  before  the  operation  so  that  even  during  sleep 
the  patient  has  felt  the  necessity  of  being  prepared 
for  emergencies  of  asphyxiation  so  that  the  sleep 
has  become  habitually  light.  Under  deep  anaesthesia 
the  patient  is  no  longer  able  to  use  his  muscles  to 
guard  against  this  difficulty  and  before  the  anaes- 
thetist notices  anything  wrong  the  patient  may  be 
in  serious  trouble.  Moreover,  'the  operation  is  at  a 
point  where  the  anaesthetist  can  readily  watch  the 
work  of  the  surgeon  unless  some  precaution  is  used 
to  prevent  this  and  consequently  the  administra- 
tion of  the  anaesthetic  may  not  receive  as  close  at- 
tention as  is  proper.  Again,  especially  in  cases  of 
exophthalmic  goitre  the  heart  has  suffered  very 
severely  as  a  result  of  the  disease  and  consequently 
the  toxic  effect  of  the  anaesthetic  is  more  serious  than 
in  other  cases.  The  manipulations  in  form  of  pressure 
and  traction  upon  the  trachea  and  larynx  often  in- 
crease the  flow  and  accumulation  of  mucus  which 
interferes  with  respiration.  Many  authors,  especially 
Landstrom,  consider  general  anaesthesia  the  greatest 


ANAESTHESIA  91 

danger  in  operations,  especially  for  the  relief  of 
exophthalmic  goitre  and  they  consequently  insist 
upon  operating  only  under  local  anaesthesia.  Moebius 
on  the  other  hand  thinks  that  the  harm  done  the 
sensitive  nervous  system  of  these  patients  is  much 
greater  than  the  harm  of  a  carefully  administered 
anaesthetic.  Crile  also  points  out  the  fact  that  mental 
excitement  greatly  increases  all  symptoms  and  that 
consequently  local  anaesthesia  should  not  be  prac- 
ticed. 

Remedies  Against  Dangers  from  Anaesthesia.  In 
many  cases  it  is  wise  to  give  the  patient  a  hypo- 
dermatic injection  of  one-quarter  of  a  grain  of  morphia 
and  one  one-hundredth  of  a  grain  of  atropine  half 
an  hour  before  operation. 

There  are  two  methods  which  may  be  employed 
to  prevent  difficulties  from  this  source. 

1.  Local  anaesthesia.  In  order  to  use  local  anaes- 
thesia successfully  it  is  necessary  to  have  a  number  of 
hypodermic  syringes  which  can  be  sterilized  and 
which  are  in  good  working  condition.  The  solution 
to  be  used  should  be  freshly  prepared  and  should  of 
course  be  sterile. 

All  preparations  should  be  made  quietly  and  with 
as  little  annoyance  or  excitement  as  possible  for  the 
patient. 

•  Unless  the  patient's  confidence  can  be  gained  be- 
fore the  administration  of  the  local  anaesthetic  is 
begun,  it  is  much  better  not  to  attempt  it  because 
the  patient  will  imagine  that  she  is  suffering  and 
this  will  be  of  almost  as  much  harm  to  her  as  actual 
pain.  It  is  consequently  especially  important  if  local 
anaesthesia  is  employed  in  operations  for  exophthal- 


92  THYROID    GLAND 

mic  goitre  that  this  condition  be  achieved.  This  is 
very  largely  a  personal  matter.  Many  surgeons  have 
the  full  confidence  of  their  patients  in  all  of  their 
undertakings  and  for  them  it  is  not  a  difficult  matter 
to  employ  this  method. 

Moreover,  in  institutions  in  which  many  of  these 
operations  are  performed  patients  encourage  e^ch 
other  and  the  new  arrivals  are  impressed  with  the 
fact  that  it  is  really  a  very  simple  matter  and  when 
they  have  once  become  convinced  of  this  fact,  it  is 
an  easy  matter  to  carry  out  any  plan. 

Choice  of  Anaesthetic.  Cocain  in  one  per  cent, 
solution  has  been  used  in  many  cases  or  to  this  may 
be  added  one-half  per  cent,  of  adrenalin  chloride 
(1  to  1000).  This  is  preferred  by  many  surgeons  be- 
cause it  reduces  the  amount  of  oozing  of  blood  from 
the  wound  surface  during  the  operation.  Landstrom 
condemns  the  use  of  adrenalin  because  he  has  ob- 
served severe  haemorrhage  after  its  effect  upon  the 
tissues  had  worn  off. 

A  two  per  cent,  solution  of  novacain  has  been 
recommended  by  others  and  again  others  recommend 
the  use  of  a  one -half  per  cent,  solution  of  beucaine 
which  is  a  synthetic  preparation  which  does  not 
degenerate  upon  boiling.  If  adrenalin  is  used  in 
connection  with  this  preparation,  however,  it  must 
be  added  after  boiling  has  been  completed.  The  ad- 
dition of  adrenalin  chloride  to  beucaine  makes  the 
anaesthesia  last  from  four  to  eight  times  longer  than 
beucaine  alone  which  is  active  for  about  fifteen  minutes . 

All  of  these  substances  should  be  dissolved  in 
normal  salt  solution;  eight  parts  of  sodium  chloride 
in  1000  parts  of  distilled  water,  sterilized  by  boiling. 


ANAESTHESIA 


93 


A  syringe  armed  with  a  fine  needle  filled 
with  any  one  of  the  above  solutions  is  employed. 
The  needle  is  inserted  into  the  skin  at  any  point 
along  the  proposed  line  of  incision,  enough  of  the 
solution  is  forced  into  the  skin  to  form  a  bleb 
one  c.  m.  in  diameter.  Then  the  needle  is  pushed 
on  into  the  skin  along  the  proposed  line  of  incision 


Fig.  18.  Anterior  view~of  patient  already  anaesthetized  and  in 
position  for  operation  with  the  head  elevated,  the  towels  a,  b,  c  in 
place,  also  pad  of  eight  thicknesses  of  gauze  placed  over  mouth  and 
nose  to  prevent  patient  from  breathing  or  coughing  into  her  own 
wound.  The  assistant  is  holding  the  jaw  upward  and  extending  the 
neck. 


and  more  of  the  fluid  is  forced  into  the  skin  until 
the  entire  line  of  incision  forms  a  continuous  row 
of  blebs  from  one  to  two  c.  m.  in  width.  A  small 
puncture  is  now  made  in  the  line  of  incision  with  a 


94  THYROID   GLAND 

large  sharp  needle,  a  Hagedorn  being  preferred,  or  a 
fine,  sharp  narrow-bladed  scalpel,  and  now  the  sharp 
needle  of  the  syringe  is  exchanged  for  a  long,  blunt 
needle  with  an  opening  on  the  side  near  its  distal  end. 
This  needle  is  introduced  through  the  needle 
puncture  and  passed  upwards  along  the  inner  border 
of  the  sterno-mastoid  muscle  and  a  small  amount  of 
the  fluid  is  forced  into  the  tissues  along  the  course  of 
the  needle.  With  a  little  practice  it  is  possible  to 
anesthetize  the  tissues  so  thoroughly  that  there  is 
absolutely  no  pain  upon  making  the  skin  incision 
and  this  will  give  the  patient  much  confidence  so 
that  if  the  remainder  of  the  operation  is  carried  out 
with  a  sufficient  amount  of  gentleness,  the  amount 
of  suffering  will  be  at  least  bearable  and  will  soon  be 
forgotten  after  the  operation  is  completed. 

It  is  this  enforced  gentleness  in  the  manipulation 
of  the  tissues  during  the  operation  which  is  really 
of  the  greatest  value  to  the  patient  because  the 
patient  cannot  and  will  not  submit  to  the  violent 
manipulations  which  the  surgeon  might  inflict  upon 
the  tissues  were  the  patient  under  the  influence  of  a 
general  anaesthesia.  Surgeons  who  are  habitually 
violent  in  their  technic  will  undoubtedly  have  better 
results  if  they  make  their  thyroidectomies  under 
local  anaesthesia. 

The  operation  may  also  be  performed  under  local 
anaesthesia  by  means  of  Schleich's  infiltration  with 
very  weak  solutions  but  the  tissues  appear  so  un- 
natural as  a  result  of  this  infiltration  that  the  diffi- 
culties are  greatly  increased. 

Moreover,  the  wounds  seem  to  be  much  more  pain- 
ful after  the  effect  of  this  local  anaesthesia  has  dis- 


ANAESTHESIA  95 

appeared    than   after    operations    performed    under 
general  anaesthesia. 

For  several  years  the  fact  that  Kocher  had  per- 
formed so  large  a  number  of  thyroidectomies  with 
local  anaesthesia  and  that  others  notably  Landstrom 
had  attributed  a  large  proportion  of  the  mortality 
following  this  operation  to  the  use  of  general  anaes- 
thesia has  caused  many  of  the  more  recent  authors 
to  treat  the  question  of  anaesthesia  in  these  cases 
as  settled  in  favor  of  local  anaesthesia.  The  following 
facts  should,  however,  not  be  overlooked;  first,  that 
real  harm  is  done  to  the  patient  by  the  mental  strain 
due  to  undergoing  an  operation  without  being  un- 
conscious  as  pointed   out,  particularly  by  Crile,  and 
Moebius,  and  second,  the  fact  that  in  Mayos'  Clinic 
and  in  Crile's  and  in  my  own,  general  anaesthesia  has 
been  practiced  in  a  much  larger  number  of  cases 
of  thyroidectomy  than  local   anaesthesia  has  been 
employed  in  any  other  clinic  with  the  exception  of 
Kocher's,  and  that  we  have  had  a  mortality  quite 
as  low  as  the  lowest  that  has  been  recorded  in  the 
clinics   where  local   anaesthesia   is   being  practiced. 
Of  course,  it  should  be  borne  in  mind  that  careless 
general    anaesthetization   must    be    absolutely    con- 
demned in  these  cases.  I  would  also  add  that  probably 
no  general  anaesthetic  except  ether  and  that  only 
when  given  by  the  drop  method,  is  at  all  safe  in 
exophthalmic  goitre.     It  may  be  an  advantage  to 
precede  the  administration  of  ether  by  the  hypo- 
dermatic administration  of  one-fourth  of  a  grain  of 
morphine    and  one  one-hundredth    of    a    grain    of 
atropine. 


96  THYROID    GlyAND 

Ether  Anaesthesia.  It  has  been  found  that  all 
patients  not  suffering  from  asphyxia  at  the  time,  of 
operation  do  well  if  ether  is  administered  in  the  foi- 
ling manner: 

After  protecting  the  patient's  eyes  by  the  appli- 
cation of  a  piece  of  guttapercha  tissue  covered  ex- 
ternally with  a  thick  layer  of  cotton,  an  ordinary 
wire  mask  such  as  is  usually  employed  in  the  admin- 
istration of  chloroform,  is  covered  with  four  to  six 
layers  of  gauze  or  two  layers  of  rather  thick  stockin- 
ette material.  This  is  placed  over  the  patient's  nose 
and  mouth,  then  the  anaesthetist  begins  to  count  and 
requests  the  patient  to  repeat  the  numbers  after  him 
slowly.  The  anaesthetist  repeats  some  number  with 
three  figures  slowly,  after  the  patient  has  repeated 
this  number  the  anaesthetist  repeats  the  next  number 
either  upwards  or  downwards  and  the  patient  again 
repeats  this.  This  plan  is  continued  until  the  patient 
has  been  very  thoroughly  anaesthetized,  the  ether 
being  dropped  slowly  but  constantly  upon  this  mask. 
By  using  this  open  mask  there  is  never  any  danger 
of  asphyxiation.  By  following  this  particular  plan 
of  counting,  the  patient's  attention  will  be  fixed 
upon  the  anaesthetist's  voice.  While  the  anaesthetist 
repeats  the  next  number  of  three  figures  the  patient 
has  sufficient  time  to  thoroughly  fill  his  lungs  by 
taking  a  deep  inspiration.  He  does  this  uncon- 
sciously and  unintentionally  in  the  preparation  for 
repeating  the  next  number.  While  he  repeats  this 
number  of  three  figures  he  unintentionally  exhales 
fully  and  is  in  condition  again  to  fill  his  lungs  thor- 
oughly by  the  next  inspiration.  Ordinarily  this  will 
result  in  from  eight  to  twelve  inspirations  per  minute. 


ANAESTHESIA  97 

The  regularity  and  monotony  of  the  performance 
has  an  excellent  effect  upon  the  patient's  nervous 
system  and  in  presence  of  a  rapid  pulse  there  is 
usually  a  marked  improvement  in  the  character  of 
the  pulse  by  the  time  the  anaesthesia  has  been  com- 
pleted. In  fact  we  have  observed  a  marked  differ- 
ence in  cases  in  which  this  method  was  employed 
and  in  those  in  which  the  patient  was  directed  to 
count  independently  from  one  upwards.  The  patient 
should  always  be  completely  anaesthetized  before 
she  is  disturbed  by  washing  the  field  of  operation 
preparatory  to  beginning  the  operation.  If  the 
patient  is  disturbed  before  full  anaesthesia  has  been 
reached,  a  stage  of  excitement  is  likely  to  be  caused 
which  will  necessitate  the  use  of  a  much  larger  amount 
of  the  anaesthetic  before  full  anaesthesia  has  been 
reached. 

After  the  patient  is  fully  anaesthetized,  the  neck 
which  has  been  carefully  prepared  the  previous 
evening  is  again  washed  with  alcohol.  A  piece  of 
gauze  saturated  with  alcohol  is  placed  over  the 
neck,  the  towels  and  sheets  separating  the  field  of 
operation  together  with  a  considerable  portion  of 
the  surrounding  area  from  the  remaining  surface 
of  the  body  are  then  adjusted.  This  requires  but  a 
few  moments,  during  which  time  the  administration 
of  the  ether  is  continued. 

Whenever  everything  is  ready  for  the  operation 
to  begin  the  ether  mask  is  removed  and  a  pad  com- 
posed of  eight  layers  of  sterile  gauze  is  placed  trans- 
versely across  the  face  thoroughly  covering  nose 
and  mouth  and  preventing  the  patient  from  breath- 
ing or  coughing  into  her  own  wound. 


98  THYROID   GLAND 

The  lower  end  of  the  table  is  now  depressed  from  an 
angle  of  30  degrees  to  45  degrees  so  that  the  patient 
is  in  the  inverted  Trendelenburg  position.  This  re- 
sults in  a  sufficient  cerebral  anaemia  so  that  the 
operation  can  be  readily  completed  without  the  ad- 
ministration of  any  additional  anaesthetic.  This 
position  has  the  further  advantage  of  reducing  the 
hemorrhage  to  quite  a  marked  extent.  In  order 
to  keep  the  respiration  unobstructed  an  assist- 
ant lifts  the  lower  jaw  forward  so  that  the 
lower  incisor  teeth  become  engaged  in  front  of  the 
upper  ones.  At  the  same  time  he  holds  the  gauze 
pad  in  place  as  shown  in  Fig.  19,  so  that  there  can 
be  no  infection  from  the  mouth  or  nose.  A  small 
pillow  placed  under  the  patient's  shoulders  causes 
the  anterior  surface  of  the  neck  to  become  prominent 
and  the  traction  by  the  assistant  exaggerates  this 
at  the  same  time  that  it  facilitates  the  patient's 
breathing. 

There  are  several  very  distinct  advantages  in  ad- 
ministering the  anaesthetic  in  this  manner.  1.  The 
patient  is  relieved  of  all  nervous  and  mental  irritation 
and  depression.  2.  The  amount  of  anaesthetic  re- 
quired is  exceedingly  small.  3.  The  heart's  action 
improves  under  this  form  of  administration  of  ethei . 
4.  The  administration  of  anaesthetic  having  ceased 
before  the  operation  is  started,  the  surgeon  can  con- 
centrate his  entire  attention  upon  the  operation 
itself.  5.  There  is  no  possibility  of  infection  from 
mouth  or  nose  or  by  the  anaesthetist  during  the  oper- 
ation. 6.  The  patient  exhales  so  much  of  the  ether 
taken  before  the  operation  is  completed  that  nausea 
and  vomiting  practically  never  occur.      7.      Upon 


ANAESTHESIA  99 

lowering  the  head,  at  the  completion  of  the  operation 
the  patient  awakens  fully  almost  immediately.  8.  It 
is  usually  possible  to  give  these  patients  sips  of  hot 
water  to  drink  shortly  after  the  operation  which  is 
an  advantage  after  operation  for  exophthalmic 
goitre.  9.  These  patients  do  not  inspire  mucous 
which  is  often  very  troublesome  when  the  anaesthetic 
is  continued  throughout  the  operation.  10.  They  are 
able  to  sit  up  at  once  when  they  return  from  the 


Fig.  19.  Lateral  view  of  patient  anaesthetized  and  in  position 
to  begin  operation.  A  pillow  has  been  placed  under  the  shoulders  in 
order  to  extend  the  neck.  The  assistant  holds  the  jaw  forward,  ex- 
tends the  neck  and  holds  the  gauze  pad  covering  the  patient's  mouth 
and  nose.  The  patient's  hair  is  carefully  covered  by  a  towel  (b)  and 
the  body  is  covered  completely  with  a  sterile  sheet  and  towels,  only 
the  neck  being  exposed. 

operating  room  which   still  further  protects  them 
against  bronchitis  and  pneumonia. 

It  seems  important  to  be  thus  explicit  because 
when  these  details  are  carried  out  one  of  the  greatest 
difficulties  in  the  way  of  thyroidectomy  for  the  re- 


100  THYROID    GLAND 

lief  of  exophthalmic  goitre  is  eliminated  in  a  very 
safe  and  simple  manner.  One  point  must  be  insisted 
upon  which  might  readily  be  overlooked,  the  task 
of  lifting  the  patient's  jaw  forward  must  be  entrusted 
to  a  reliable,  intelligent  and  trained  assistant  and 
not  to  any  one  who  may  accidentally  be  available  and 
is  unfit  for  any  other  duty.  In  one  instance,  I  have 
observed  an  almost  fatal  asphyxia  because  this 
assistant  relaxed  his  hold  upon  the  lower  jaw  after 
the  gland  had  already  been  removed.  This  permitted 
the  tongue  to  fall  back  into  the  pharynx  and  to  ob- 
struct the  respiration  completely.  The  surgeon  did 
not  know  this  had  happened  until  he  noticed  a 
deep  cyanosis  in  the  flap.  Then  he  immediately 
drew  forward  the  tongue,  lowered  the  head  of  the 
table  and  performed  artificial  respiration.  Fortu- 
nately the  patient  had  not  advanced  in  her  disease 
to  the  stage  of  advanced  myocarditis,  a  condition 
so  commonly  found  in  connection  with  exophthalmic 
goitre  and  consequently  the  patient  recovered  which 
would  have  been  quite  unlikely  in  a  more  advanced 
case. 

Rectal  Anaesthesia.  The  advantages  of  this 
method  must  be  apparent  if  further  experience  does 
not  show  harmful  effects. 

The  following  advantages  are  claimed  for  the 
method  by  those  who  have  employed  it. 

1.  The  amount  of  ether  employed  is  very  much 
smaller  than  by  the  inhalation  method. 

2.  There  is  no  stage  of  excitation. 

3.  There  is  no  irritation  of  the  respiratory  mucous 
membranes. 


ANAESTHESIA  101 

4.  The  anaesthetist  does  not  approach  the  field 
of  operation. 

5.  Besides  being  out  of  the  way  he  also  is  unable 
to  infect  the  wound. 

6.  The  patient  awakens  almost  at  once  after  the 
anaesthetic  is  stopped. 

7.  There  is  said  to  be  less  nausea  and  vomiting 
probably  because  the  patient  has  not  swallowed 
quantities  of  mucous  saturated  with  ether. 

8.  There  is  no  depressing  effect  upon  the  heart. 

It  is,  however,  to  be  remembered  that  all  of  these, 
advantages  are  also  obtained  if  the  method  is  em- 
ployed which  has  just  been  described  of  thoroughly 
anaesthetizing  the  patient  by  the  inhalation  method 
and  then  stopping  the  anaesthetic  and.  elevating  the 
head  during  the  operation. 

Method  of  Application.  It  is  most  important 
that  the  colon  be  empty  at  the  time  of  administra- 
tion of  ether  by  rectum,  because  the  presence  of 
faeces  will  prevent  the  rapid  absorption  of  ether  and 
the  openings  in  the  tube  through  which  the  ether 
fumes  are  introduced,  may  become  clogged  and  thus 
the  introduction  in  sufficient  quantities  may  be  pre- 
vented. 

In  order  to  secure  an  empty  colon,  two  ounces  of 
castor  oil,  preferably  in  beer  foam,  should  be  given 
twenty-four  hours  before  the  operation,  twelve  hours 
later  the  patient  should  receive  a  large  cleansing 
enema  of  soap  suds  and  normal  salt  solution  and  the 
latter  should  be  repeated  three  hours  before  the 
operation.  In  the  meantime,  no  food  should  be  given 
except  broths  and  gruels  in  order  that  there  may  not 
be  any  fresh  accumulation. 


102  THYROID    GLAND 

Technic.  The  patient  is  placed  upon  the  table 
the  surface  of  the  neck  thoroughly  prepared  and 
then  covered  with  a  piece  of  sterile  gauze  saturated 
with  alcohol.  The  hair  is  covered  and  a  gauze  pad  is 
placed  across  the  mouth  and  nose  as  described  in 
Fig.  19,  in  fact  the  preliminary  preparation  is 
identical  with  that  employed  if  the  operation  is 
to  be  performed  under  ether  anaesthesia  by  inspira- 
tion. An  assistant  also  draws  the  lower  jaw  forward 
as  described  above,  and  holds  it  in  that  position 
throughout  the  operation. 

An  ordinary  soft  rubber  rectal  tube  with  an  opening 
at  the  end  is  then  introduced  into  the  rectum  slowly 
a  distance  of  eight  or  ten  inches.  The  tube  should 
be  thoroughly  lubricated  in  order  to  prevent  annoy- 
ance by  friction.  The  gas  contained  in  the  rectum  is 
thus  permitted  to  escape  in  order  to  facilitate  the 
absorption  of  ether.  The  rectal  tube  is  then  attached 
to  the  tube  through  which  the  ether  fumes  are  pump- 
ed into  the  rectum.  The  colon  is  then  slowly  filled 
with  ether  fumes  and  then  the  rectal  tube  is  once 
more  disconnected  in  order  that  the  remaining  in- 
testinal gas  which  was  not  evacuated  primarily  may 
escape.  This  procedure  may  be  repeated  several 
times,  care  being  taken  that  the  ether  fumes  are  not 
injected  too  rapidly  for  fear  of  causing  too  great 
distension  or  irritation.  At  first  some  gas  may  escape 
along  the  side  of  the  rectal  tube  but  this  can  soon  be 
prevented  by  injecting  only  just  enough  gas  to  fill 
the  colon.  There  may  be  slight  colicky  pains  at  first 
but  the  patient  will  soon  become  accustomed  to 
the  sensation.  If  the  castor  oil  and  the  enema  have 
acted  satisfactorily,  there  will  be  no  annoyance  from 


ANAESTHESIA  103 

defecation  or  clogging  of  the  rectal  tube.  The  full 
anaesthesia  will  occur  in  from  five  to  fifteen  minutes 
and  the  operation  can  be  performed  with  the  con- 
sumption of  from  one  to  three  ounces  of  ether.  When 
the  operation  is  completed  to  the  point  of  suturing 
the  external  wound,  the  apparatus  is  detached  from 
the  rectal  tube  and  the  accumulated  gas  in  the  colon 
will  be  permitted  to  escape.  If  the  patient  is  slightly 
conscious  of  the  application  of  the  skin  sutures,  the 
consequent  deep  breathing  will  facilitate  the  excre- 
tion of  most  of  the  ether  contained  in  the  blood 
through  the  expired  air.  It  also  facilitates  the  ex- 
pulsion of  any  ether  fumes  which  may  still  remain 
in  the  colon.  This  can  be  further  facilitated  by  mak- 
ing gentle  abdominal  massage. 

The  patient  must  be  observed  throughout  the 
period  of  administration  with  the  same  care  as  when 
ether  is  given  through  the  respiratory  tract.  Cyanosis 
will  almost  never  occur  if  the  lower  jaw  is  held  for- 
ward as  indicated  in  Fig.  19.  The  pulse  and  respira- 
tion will  indicate  the  progress  of  the  anaesthesia. 
It  is  rarely  necessary  to  disconnect  the  rectal  tube 
from  the  apparatus  and  to  make  abdominal  massage 
to  force  the  ether  fumes  out  of  the  rectum  during  the 
operation,  but  in  case  of  necessity  this  could  be 
readily  done.  If  the  head  is  elevated  after  the  opera- 
tion is  begun  almost  no  anaesthetic  will  be  required 
during  the  actual  progress  of  the  operation. 

Apparatus.  Various  forms  of  retainers  have  been 
invented  for  producing  the  ether  fumes  utilized  in 
this  form  of  anaesthesia.  A  simple  deep  bottle  con- 
structed on  the  general  plan  of  wash  bottles  used  in 
chemical  laboratories  seem  to  suffice  perfectly  pre- 


104  THYROID    GLAND 

ferably  mounted  on  a  stand  which  can  easily  be 
moved  without  breaking  the  bottle  or  its  attach- 
ments. The  bottle  contains  a  rubber  stopper  with 
two  holes  one  of  which  contains  a  glass  tube  whose 
lower  end  is  even  with  the  stopper  and  whose  upper 
end  is  attached  to  a  rubber  tube  which  at  its  other 
end  contains  a  glass  tube  for  attachment  to  the 
rectal  tube.  The  other  hole  contains  a  glass  tube 
with  bulb -shaped  lower  end  containing  many  small 
perforations  and  reaching  to  the  bottom  of  the  bottle. 
The  upper  end  of  this  tube  projects  through  the  upper 
surface  of  the  rubber  stopper  a  sufficient  distance  to 
permit  the  attachment  of  a  rubber  tube  the  other 
end  of  which  is  attached  to  a  bulb  with  which  air 
can  be  forced  into  the  bottle.  The  bottle  should  be  at 
least  thirty  centimeters  deep  so  that  the  air  can  be 
forced  through  a  considerable  column  of  ether.  The 
bottle  is  filled  with  ether  to  a  point  five  cm.  from 
the  lower  surface  of  the  cork,  the  upper  portion  of 
the  bottle  being  left  as  a  gas  space. 

This  bottle  should  be  immersed  in  a  vessel  con- 
taining water  at  a  temperature  of  from  80°  to  100°  F. 
according  to  various  clinicians  the  boiling  point  of 
ether  being  98.6  F.  A  thermometer  placed  in  the 
water  is  to  be  added  and  a  stop-cork  at  the  lower 
part  will  make  it  possible  to  remove  the  water  when 
the  temperature  has  become  too  low. 

According  to  another  method  which  has  also  been 
frequently  used  and  apparently  with  equally  satisfac- 
tory results  the  arrangement  for  blowing  through  the 
ether  is  dispensed  with ;  a  simple  flask  being  employed 
containing  a  rubber  cork  fitted  with  a  glass  tube 
whose  lower  end  is  even  with  the  lower  end  of  the 


ANAESTHESIA  105 

rubber  stopper.  To  the  upper  end  of  this  a  glass  tube 
is  attached  which  in  turn  is  attached  to  the  rectal 
tube  by  means  of  an  intervening  glass  tube.  Some 
surgeons  prefer  to  have  this  attachment  made  by 
means  of  an  intervening  rubber  tube  which  is  fitted 
with  a  stopcork  so  that  the  flow  of  the  ether  fumes 
may  be  interrupted  at  any  time. 

The  flask  containing  the  ether  is  then  immersed 
in  a  waterbath  at  a  temperature,  of  105°  F.  which 
will  cause  ether  to  evaporate  with  sufficient  rapidity 
to  bring  about  the  anaesthesia.  In  case  the  amount 
evaporated  is  not  sufficient  the  temperature  may  be 
increased.  If  the  evaporation  is  too  rapid,  the  flask 
may  be  raised  out  of  the  waterbath  either  partly 
or  completely  until  it  again  becomes  desirable  to 
increase  the  amount  of  ether  fumes. 

The  method  is  so  simple  that  any  one  who  has 
seen  it  applied  once  can  readily  administer  ether 
in  this  way,  but  it  seems  worth  while  to  be  explicit 
in  the  description  of  this  method  because  it  has  not 
as  yet  received  practical  application  to  a  sufficient 
extent  to  become  familiar  by  demonstration.  By 
substituting  a  good  sized  thermos  bottle  for  the  con- 
tainer of  the  warm  water,  with  a  rubber  cork  that 
fits  closely  around  the  upper  end  of  the  bottle  con- 
taining the  ether,  the  apparatus  can  be  still  further 
improved  because  the  water  will  then  maintain  a 
fairly  uniform  temperature  throughout  the  opera- 
tion and  the  slight  decrease  in  temperature  will  be 
rather  an  advantage  than  a  disadvantage. 

Spinal  Anaesthesia.  A  few  enthusiasts  have  de- 
scribed methods  by  which  spinal  anaesthesia  may  be 
employed  in  thyroid  operations.    It  is  plain  that  no 


106  THYROID    GLAND 

one  whose  judgment  has  not  been  impaired  by  the 
desire  to  accomplish  that  which  is  unusual  would 
expose  a  patient  already  so  severely  handicapped  to 
the  direct  application  of  cocaine  to  the  upper  por- 
tion of  the  spinal  cord.  I  simply  mention  this  method 
to  express  the  opinion  that  it  should  never  be  em- 
ployed in  these  cases. 

High  Spinal  Anaesthesia  by  the  use  of  Stovaine 
and  Neutral  Sulphate  of  Strychnine.  During  the  past 
eighteen  months  Prof.  Thomas  Jonnesco  has  tried 
high  spinal  analgesia  for  many  different  operations 
upon  the  head  and  neck  in  more  than  150  cases  with- 
out any  fatality  and  without  any  serious  after  effect. 
It  therefore  seems  proper  to  describe  this  method, 
although  it  does  not  seem  wise  at  the  present  moment 
to  recommend  it  in  operations  for  goitre  as  the  ex- 
perience is  still  limited. 

The  following  directions  are  taken  from  Prof. 
Jonnesco's  article  in  the  British  Medical  Journal: 

The  Preparation  of  the  Solution.  The  solution 
must  be  made  at  the  time  when  the  operation  is  to 
be  performed  as  follows:  The  necessary  quantity 
of  stovaine  is  introduced  into  a  glass  tube  provided 
with  an  india  rubber  stopper,  and  sterilized  in  the 
autoclave.  The  substance  need  not  be  sterilized 
since  it  is  itself  antiseptic,  and  some  of  its  properties 
would  be  destroyed  by  heat. 

The  strychnine  solution  is  made  by  dissolving  5 
c.  c.  of  neutral  strychnine  sulphate  in  100  grams  of 
sterilized  (not  distilled)  water  in  a  glass-stoppered 
bottle  previously  sterilized;  1  c.  c.  of  the  solution 
will  contain  5  mg.  As  the  strychnine  takes  some 
time  to  dissolve,  it  is  better  to  prepare  this  solution 


ANAESTHESIA  107 

a  little  before  the  time  when  it  has  to  be  used.  With 
an  ordinary  Pravaz  syringe  provided  with  a  needle 
for  lumbar  puncture,  1  c.  c.  of  the  solution  of  strych- 
nine is  drawn  up  and  is  injected  into  the  tube 
containing  the  dose  of  stovaine  judged  to  be  neces- 
sary for  the  puncture  about  to  be  made.  The  tube 
is  corked  again,  and  shaken,  and  the  salts  are  dis- 
solved. The  same  syringe  is  then  filled  with  the 
contents  of  the  tube  and  is "  held  with  a  sterilized 
compress  and  removed  from  the  needle  while  the 
puncture  is  being  made;  3  c.  c.  of  stovaine  is  the 
usual  dose  for  adults. 

Upper  Dorsal  Puncture.  Upper  dorsal  punc- 
ture between  the  first  and  second  dorsal  vertebrae 
is  easily  performed;  the  landmark  is  the  vertebra 
prominens  with  the  visible  and  tangible  protuber- 
ances of  the  spinous  processes  of  the  second  and  third 
dorsal  vertebrae.  When  the  patient's  head  is  strong- 
ly flexed,  so  that  the  chin  touches  the  sternum,  the 
protuberances  are  very  marked,  and  the  spaces 
they  bound  are  enlarged.  The  patient  being  placed 
in  this  position,  the  surgeon  marks  with  the  fore- 
finger of  his  left  hand  the  space  between  the  first 
and  second  dorsal  vertebrae,  and  the  needle,  held 
between  the  finger  and  thumb  of  the  right  hand,  is 
pushed  in,  following  the  upper  border  of  the  spinous 
process  of  the  second  dorsal  vertebra. 

The  Injection.  As  soon  as  the  escape  of  cerebro- 
spinal fluid  renders  it  certain  that  the  arachnoid 
space  has  been  entered,  its  further  loss  should  be 
stopped,  for  I  am  convinced  that  the  escape  of  more 
than  a  certain  quantity  of  fluid  is  rather  harmful 
-than  useful.     The  loss  of  too  much  fluid   (1)   may 


108  THYROID    GLAND 

cause  signs  of  faintness,  pallor  of  the  face,  sweat- 
ing, etc. ;  and  (2)  by  suddenly  diminishing  the 
quantity  of  cerebro-spinal  fluid  may  cause  too  rapid 
diffusion  of  the  anaesthetic,  which  is  undesirable 
and  may  be  mischievous.  As  soon,  then,  as  a  few 
drops  of  fluid  escape,  the  needle  is  closed  with  the 
forefinger  of  the  left  hand,  while  with  the  right  the 
syringe  filled  with  the  anaesthetic  mixture  is  adapted 
to  the  needle.  The  liquid  must  be  slowly  injected 
so  as  not  to  produce  an  undue  impact  upon  the  spinal 
cord. 

Position  of  Patient  after  Injection.  "The  posi- 
tion to  be  assumed  by  the  patient  after  the  in- 
jection, so  as  to  ensure  analgesia  of  the  region  to  be 
operated  upon,  is  a  cardinal  point,  for  by  attention 
to  it  we  can  favor  the  distribution  of  the  liquid  in 
the  desired  direction.  If  with  the  higher  dorsal 
injection  it  is  desired  to  obtain  analgesia  of  the  head 
and  neck,  the  patient  is  made  to  lie  on  his  back  if 
the  operation  is  to  be  on  the  throat,  the  head  should 
be  a  little  raised ;  if  on  the  face  or  skull,  he  should  lie 
horizontally;  if  on  the  upper  limb  or  thorax  bent 
slightly  forward.  If  after  four  or  five  minutes 
the  analgesia  of  the  head  or  of  the  neck  is  not  com- 
plete, the  patient's  head  should  be  lowered  below 
the  level  of  the  body  for  three  or  four  minutes." 

Morphin  and  Hyoscin.  A  number  of  surgeons 
have  administered  from  one-sixth  to  one-third  of  a 
grain  of  morphin  with  one  one-hundredth  of  a  grain 
of  hyocin  hypodermically  from  twenty  to  forty 
minutes  before  beginning  the  administration  of  ether 
in  order  to  reduce  the  quantity  of  the  latter  drug 
required. 


ANAESTHESIA  109 

In  the  same  manner  one  one-hundreclth  of  a  grain 
of  atropin  has  been  combined  with  the  morphin  for 
the  same  purpose.  There  is  no  doubt  but  that  both 
of  these  combinations  will  reduce  the  amount  of 
ether  required,  but  whether  this  advantage  is  suffi- 
cient to  balance  the  disadvantage  of  subjecting  these 
patients  to  the  effect  of  these  powerful  drugs  does 
not  seem  clear. 


CHAPTER  VI. 


DANGERS  OF  OPERATION. 


Shock.  Until  Billroth  and  Kocher  demonstrated 
the  fact  that  shock  can  be  very  largely  eliminated 
from  this  operation,  the  surgical  profession  laid  great 
stress  upon  this  element  and  this  fear  has  caused 
many  surgeons,  even  to  the  beginning  of  the  present 
century,  to  hesitate  before  recommending  this  oper- 
ation to  their  patients.  Kocher's  statistics  and  his 
daily  demonstrations  to  surgeons  from  all  parts  of 
the  world,  and  again  the  results  of  his  many  disciples, 
have  served  to  dispel  this  fear.  In  America,  the 
work  of  C.  H.  Mayo  has  served  especially  to  bring 
about  similar  results  more  particularly  in  the  sur- 
gery dealing  with  exophthalmic  goitre.  If  the  surgeon 
proceeds  systematically  with  a  thorough  knowledge 
of  the  regional  anatomy  to  be  encountered  in  this 
operation,  if  he  is  reasonably  skillful  so  that  he  can 
complete  the  operation  in  a  comparatively  short 
time,  if  he  has  the  ability  of  working  without  un- 
reasonably traumatizing  the  tissues  and  if  he  is 
careful  to  secure  the  vessels  before  they  are  severed 
in  order  to  minimize  the  loss  of  blood,  then  he  need 
not  fear  the  element  of  shock.  To  this  should  be 
added  good  judgment  in  selecting  the  proper  time 
for  operation  especially  in  exophthalmic  goitre. 

Haemorrhage.  In  connection  with  prevention  of 
haemorrhage  we  are  again  indebted  to  Kocher  for 


DANGERS    OF    OPERATION  111 

the  greatest  progress.  He  pointed  out  the  import- 
ance of  keeping  the  field  free  from  blood  and  demon- 
strated a  method  with  the  use  of  his  director  and  his 
reliable  haemostatic  forceps  by  means  of  which  this 
could  be  very  readily  accomplished.  These  will  be 
discussed  and  illustrated  in  connection  with  the 
technical  description  of  the  operations. 

It  is  important  to  bear  in  mind  that  the  veins  are 
usually  dilated  to  many  times  the  normal  size  and 
that  consequently  great  care  must  be  exercised  be- 
cause a  tear  in  the  walls  of  one  of  these  vessels  will 
result  in  the  loss  of  a  considerable  amount  of  blood. 
Moreover,  it  is  not  only  the  loss  of  the  blood  that  is 
to  be  deplored  but  the  fact  that  the  field  of  operation 
is  obscured  and  consequently  the  progress  of  the 
operation  is  retarded  and  successive  vessels  to  be 
grasped  may  be  overlooked  causing  unnecessary 
haemorrhage.  Besides  this,  Kocher  claims  that  the 
blood  itself  in  these  cases  has  a  considerable  degree 
of  toxicity  so  that  the  patients  whose  wound  surfaces 
have  been  free  from  blood  make  a  better  recovery 
than  those  in  whom  the  surfaces  have  been  drenched 
with  blood.  Of  course,  excessive  haemorrhage  always 
increases  the  shock  in  three  ways:  1,  by  prolonging 
the  operation;  2,  by  increasing  the  amount  of  man- 
ipulation and  3,  by  the  loss  of  blood  itself. 

Hyperthyroidism.  Whoever  has  operated  fre- 
quently for  the  removal  of  thyroid  glands  must  have 
become  impressed  with  the  real  danger  to  the  patient 
from  postoperative  hyperthyroidism  due  either  to 
the  absorption  of  thyroid  secretion  pressed  out  of 
the  gland  and  into  the  circulation  during  the  opera- 
tion or  of  thyroid  secretion  or  toxic  blood  absorbed 


112  THYROID    GLAND 

from  the  wound  surface.  It  seems  that  all  surgeons 
who  have  operated  for  many  years  can  recall  numer- 
ous instances  from  the  early  cases  while  their  later 
experience  has  been  relatively  free  from  this  com- 
plication. Moreover,  a  number  of  surgeons  have  re- 
ported a  greater  number  of  patients  suffering  from 
hyperthyroidism  while  they  operated  under  ether  or 
chloroform  anaesthesia,  than  after  changing  to  local 
anaesthesia.  It  seems  clear  that  under  local  anaes- 
thesia what  might  be  called  violent  surgery  is  not 
possible,  because  the  patient  would  not  submit  to  it 
while  awake  even  though  the  tissues  might  be  numb- 
ed to  a  considerable  extent  by  the  use  of  local 
anaesthetics.  It  is  often  difficult,  when  the  patient 
is  thoroughly  anaesthetized,  to  conduct  every  step 
of  the  operation  not  only  the  part  accomplished  by 
the  surgeon  but  that  carried  out  by  the  assistants 
without  unduly  traumatizing  the  tissues. 

In  this  connection  it  may  be  well  to  refer  to  the 
value  of  drainage  for  from  one  to  three  days  after 
the  operation.  There  is  usually  a  considerable  amount 
of  oozing  of  blood  and  serum  and  where  a  layer  of 
the  posterior  portion  of  the  gland  is  left  in  place  to 
protect  the  recurrent  laryngeal  nerve  and  the  par- 
athyroid glands  there  is  always  some  thyroid  secre- 
tion that  exudes  into  the  wound  and  it  seems  well  to 
insist  upon  making  some  provision  which  will  rapidly 
carry  these  fluids  beyond  the  absorbing  surfaces.  I 
have  seen  violent  hyperthyroidism  in  two  of  my  own 
cases  in  which  it  had  seemed  unnecessary  to  provide 
for  free  drainage.  I  am  confident  that  in  both  of 
these  cases  this  calamity  might  have  been  prevented 
by  the  use  of  free  drainage  to  be   described   later. 


DANGERS    OF    OPERATION  113 

Above  all  things  it  seems  important  to  be  gentle  in 
the  manipulation  of  the  thyroid  gland  itself. 

Injury  to  Parathyroid  Glands.  A  study  of  the 
discussion  of  the  parathyroid  glands  in  the  later 
chapters  of  this  book  convinces  the  reader  that  in- 
jury of  these  glands  must  not  occur  during  opera- 
tions upon  the  thyroid  gland.  In  the  early  days  of 
thyroidectomy  these  injuries  were  numerous  as 
shown  by  the  statistics  already  quoted.  As  soon  as 
the  importance  of  these  glands  was  generally  recog- 
nized these  calamities  virtually  disappeared  because 
as  will  be  shown  in  connection  with  the  discussion 
of  the  surgical  anatomy  involved,  it  is  an  exceedingly 
simple  matter  to  avoid  injuring  these  important 
structures.  In  the  meantime  it  is,  however,  impor- 
tant always  to  bear  in  mind  the  fact  that  this  is 
really  a  vital  organ  from  the  standpoint  of  the 
clinical  surgeon  and  that  nothing  can  be  more  im- 
portant than  a  careful  study  of  all  that  is  known 
about  this  structure.  The  anatomical  position  of 
these  glands  made  their  removal  almost  certain  dur- 
ing the  early  operations  because  they  are  so  inti- 
mately attached  to  the  posterior  surface  of  the 
capsule  of  the  thyroid  gland,  but  it  is  this  very  fact 
which  has  made  it  so  easy  to  preserve  these  glands 
since  their  importance  has  been  recognized.  That 
these  glands  can  be  restored  by  transplantation  has 
been  demonstrated  many  times  in  animals  and  von 
Eiselsberg,  who  reports  one  successful  case  in  the 
human  patient,  thinks  that  it  is  justifiable  to 
take  a  gland  from  a  donor  only  when  one  can  be 
certain  that  he  has  three  other  healthy  glands  or 
virtually  only  in  cases  operated  for  cyst  of  one  lobe 


114  THYROID    GLAND 

of  the  thyroid  gland.  Pool  also  reports  a  most  inter- 
esting case  and  discusses  the  subject  thoroughly. 

Infection.  In  preantiseptic  days  this  was  the 
most  feared  of  all  complications  because  an  infection 
usually  resulted  in  a  septic  mediastinitis  which  in 
turn  proved  fatal  to  the  patient.  The  infection  could 
readily  extend  along  the  vessels  of  the  neck  into  the 
mediastinal  space. 

Since  the  introduction  of  aseptic  surgery  this 
danger  has  practically  disappeared  in  the  hands  of 
surgeons  who  are  otherwise  qualified  to  undertake 
the  operative  treatment  of  goitre.  At  the  present 
time  hospitals  in  which  such  operations  are  perform- 
ed are  so  perfectly  equipped  and  assistants  and 
nurses  are  so  thoroughly  trained  that  infections  from 
implements,  instruments,  sponges,  dressings  and  the 
hands  of  operator  or  assistants  or  nurses  is  almost 
impossible. 

There  are  two  sources  which  are  always  present 
which  cannot  be  so  absolutely  eliminated  unless  es- 
pecial stress  is  laid  upon  certain  precautions  and 
unless  the  attention  of  everyone  is  especially  directed 
to  these  details.  I  refer  to  the  difficulty  of  protecting 
the  patient  against  infection  from  her  own  mouth 
and  nose  and  the  difficulty  one  often  experiences  in 
keeping  the  surrounding  areas  together  with  the 
ears  and  hair  of  the  patient  thoroughly  covered 
throughout  the  operation  to  prevent  infecting  some- 
thing by  contact  with  these  parts  and  later  bringing 
the  infected  object  in  contact  with  the  wound. 

Unless  an  intelligent  assistant  is  especially  en- 
trusted with  keeping  mouth  and  nose  covered 
throughout  the  operation  and  unless  this  is  his  only 


DANGERS    OF    OPERATION  115 

duty  with  the  possible  addition  of  keeping  the  lower 
jaw  forward  it  may  easily  happen  that  the  patient 
may  cough  or  breathe  infectious  matter  into  her  own 
wound.  As  difficult  as  it  may  seem  to  protect  the 
patient  against  incidental  contact  infection  so  easy 
it  becomes  when  all  details  have  been  systematically 
arranged. 

It  is  not  at  all  important  that  these  details  be  uni- 
form in  the  work  of  different  surgeons  but  it  is  ex- 
ceedingly important  for  each  surgeon  to  develop 
some  satisfactory  system  which  is  regularly  carried 
out  in  all  of  his  operations  upon  the  thyroid  gland. 

Injury  to  the  Parathyroid  Glands  and  the  Re- 
current Laryngeal  Nerve.  This  danger  is  es- 
pecially enumerated  only  because  in  the  early 
operations  upon  the  thyroid  gland  it  was  not  at  all 
uncommon,  which  will  be  readily  understood  when 
we  come  to  consider  the  surgical  anatomy  involved. 
Fortunately  the  same  precautions  which  serve  to 
protect  the  parathyroid  glands  will  serve  to  prevent 
the  injury  to  the  recurrent  laryngeal  nerve. 

The  injury  may  occur  by  cutting  the  nerve  at  the 
point  at  which  it  passes  between  the  posterior  sur- 
face of  the  thyroid  gland  and  the  trachea ;  or  it  may 
be  caused  by  crushing  with  haemostatic  forceps  in 
attempting  to  grasp  the  inferior  thyroid  vessels  or 
their  branches.  What  has  been  said  regarding  pre- 
vention of  haemorrhage  should  be  repeated  here.  If 
all  the  vessels  are  caught  before  they  are  severed  the 
field  of  operation  will  not  be  obscured  and  other 
structures  will  not  be  injured.  As  a  result  of  this 
injury,  there  is  a  paralysis  of  the  vocal  cord  on  one 
side  which  is,  of  course,  a  serious  matter. 


116  THYROID    GLAND 

Air  Embolism.  The  thinness  of  the  vein  walls 
makes  air  embolism  quite  unlikely  although  it  must 
of  course  be  borne  in  mind  in  connection  with  this 
as  with  all  other  operations  which  are  performed  in 
the  vicinity  of  the  large  veins  of  the  neck.  If  the 
precautions  mentioned  in  connection^  with  the  meth- 
ods advised  for  prevention  of  haemorrhage  are  carried 
out  there  is  still  less  likelihood  of  the  occurrence  of 
this  accident. 

Air  embolism  occurs  only  when  a  considerable 
quantity  of  air  enters  a  vein  at  one  time.  Usually 
this  occurs  when  the  vein  walls  are  cut  and  the  in- 
cision is  held  open  either  artificially  as  by  means  of 
forceps  or  by  surrounding  non-elastic  structures  as 
in  case  the  vein  is  surrounded  by  lymph  nodes  which 
have  been  invaded  by  carcinoma  or  infected  by 
tuberculosis.  As  these  conditions  are  almost  never 
present  in  cases  in  which  operations  upon  the  thyroid 
gland  are  indicated  this  complication  must  be  ex- 
tremely rare  in  connection  with  thyroid  operations. 

Collapse  of  the  Trachea.  Almost  every  surgeon 
who  has  frequently  operated  for  the  removal  of  dis- 
eased thyroid  glands  has  encountered  cases  in  which 
the  trachea  has  collapsed  as  soon  as  it  has  lost  its 
support  due  to  its  attachment  to  the  thyroid  gland. 
The  cartilages  of  the  trachea  may  become  exceeding- 
ly soft  and  pliable  or  they  may  practically  disappear 
as  a  result  of  pressure  atrophy  caused  by  the  enlarged 
thyroid  gland.  The  patient  then  shows  immediately 
symptoms  of  asphyxia.  The  more  violent  the  efforts 
at  inspiration  the  more  complete  will  be  the  obstruc- 
tion because  the  anterior  wall  of  the  trachea  is  drawn 
into  the  lumen  of  this  tube  like  a  valve  and  the 


DANGER    OF    OPERATIONS  117 

further  it  is  drawn  in  the  more  completely  will  the 
valve  close  the  lumen  of  the  tube.  If  the  surface  of 
the  wound  has  been  kept  fairly  free  from  blood  one 
can  easily  see  the  anterior  wall  drawn  in  but  if  there 
is  much  blood  on  the  surface  of  the  wound  it  may 
not  be  possible  to  recognize  the  condition  by  direct 
inspection.  In  that  case  it  may  be  confounded  with 
sudden  collapse  of  the  patient  or  if  an  anaesthetic 
has  been  administered  throughout  the  operation  the 
difficulty  may  be  attributed  to  the  anaesthetic;  of 
course,  the  usual  methods  of  restoring  the  patient 
for  collapse  due  to  anaesthesia  will  be  quite  useless 
and  in  the  meantime  the  asphyxia  with  the  weak 
condition  of  the  patient  may  result  in  a  fatal  ending. 
Again,  it  may  occur  that  a  large  middle  lobe  may 
have  been  lodged  behind  the  sternum  and  when  the 
latter  lobe  has  been  severed  from  its  attachments 
posteriorly  and  externally,  but  is  still  attached  to  the 
middle  lobe  internally,  the  traction  made  may 
carry  the  middle  lobe  upward  sufficiently  to  make 
severe  pressure  upon  the  trachea  just  behind  the 
upper  end  of  the  sternum  and  this  in  turn  may  give 
rise  to  asphyxia  which  may  be  mistaken  for  the  same 
condition  due  to  collapse  of  the  trachea.  In  order  to 
avoid  unfortunate  results  of  collapse  of  the  trachea 
it  is  best  to  keep  in  readiness  a  reliable  mouth  gag 
and  intubation  apparatus.  If  this  cannot  be  employ- 
ed it  is  well  to  insert  two  sharp  tenaculae  into  the 
collapsed  portion  of  the  trachea  and  to  draw  the 
latter  forward. 

If  this  succeeds  in  giving  relief  an  apparatus  must 
be  arranged  which  will  maintain  the  anterior  tracheal 
wall  in  this  position.    If  this  is  not  possible  a  longi- 


118  THYROID    GLAND 

tudinal  incision  should  be  made  as  in  ordinary 
tracheotomy  and  a  tube,  which  should  always  be  kept 
in  readiness,  should  be  inserted.  If  no  tracheotomy 
tube  is  available  it  will  be  an  easy  matter  to  make 
some  contrivance  which  will  keep  the  incision  open 
so  air  can  enter  freely. 

This  opening  should  be  covered  with  four  thick- 
nesses of  sterile  gauze  in  order  to  prevent  infection 
which  might  easily  result  in  pneumonia.  If  an  in- 
tubation has  been  used  this  should  be  removed  on 
the  fifth  day  in  order  to  reduce  as  much  as  possible 
the  injury  done  by  the  intralaryngeal  pressure  of  the 
tube.  If  the  breathing  is  not  free  after  the  tube  has 
been  removed  it  is  well  to  replace  the  latter  for  two 
or  three  days  when  the  same  experiment  should  be 
repeated. 


CHAPTER  VII. 


INDICATIONS     FOR    OPERATION     ON    THE 
THYROID  GLAND. 


Indications  for  Operative  Treatment.  Primarily 
the  indication  for  operative  treatment  of  simple 
goitre  must  be:  1,  inability  to  relieve  the  condition 
by  non-surgical  means ;  2,  distress  from  pressure  upon 
the  trachea;  3,  pressure  upon  the  trachea  and  the 
oesophagus;  4,  pain  from  pressure;  5,  unsightly  de- 
formity; 6,  discomfort  due  to  the  weight  of  the  en- 
larged gland;  7,  increasing  symptoms  of  exophthal- 
mic goitre  also  not  yielding  to  non-surgical  treatment. 

1 .  As  has  been  stated  before  a  very  large  propor- 
tion of  all  patients  suffering  from  non-malignant 
diseases  of  the  thyroid  gland  can  undoubtedly  be 
relieved  by  non-surgical  treatment  provided  this  is 
applied  systematically  and  continued  for  a  consider- 
able period  of  time  after  the  patient  has  apparently 
recovered.  Hygienic  and  dietetic  and  medicinal 
treatment  should  consequently  be  systematically 
employed  in  each  case  at  its  beginning  and  only  after 
failing  after  these  methods  have  been  carefully  em- 
ployed should  the  surgical  treatment  be  resorted  to 
and  then  only  if  the  disease  has  produced  conditions 
that  would  warrant  the  undertaking  of  an  operation 
requiring  a  considerable  amount  of  skill  and  ex- 
perience. 


120  THYROID    GLAND 

In  many  cases  there  is  so  marked  a  degree  of  pres- 
sure upon  the  trachea  that  the  patient  cannot 
breathe  with  any  comfort.  This  may  be  constant 
or  it  may  only  occur  when  the  patient  is  in  the  re- 
cumbent position.  This  may  be  due  to  a  general 
pressure  from  all  of  the  lobes  or  the  middle  lobe  may 
contain  a  circumscribed  mass  which  may  press 
directly  upon  the  trachea  and  may  act  like  a  ball 
valve  applied  to  the  outside  of  the  tracheal  tube  fre- 
quently causing  the  softening  of  one  or  more  of  the 
tracheal  cartilages.  This  is  more  commonly  due  to 
pressure  from  a  portion  of  the  middle  lobe  projecting 
downward  behind  the  sternum.  In  one  instance  the 
patient,  a  young  woman,  was  unconscious  as  a  re- 
sult of  asphyxia  caused  by  the  condition  just  de- 
scribed, when  I  was  called  to  give  her  relief.  Her  con- 
dition was  so  serious  that  I  at  once  proceeded  to 
secure  local  anaesthesia  by  injecting  one  per  cent, 
of  cocaine  solution  into  the  skin.  The  operation  was 
performed  immediately  with  the  greatest  possible 
speed,  with  the  patient  in  this  unconscious  asphyx- 
iated condition.  No  air  seemed  to  pass  in  either  di- 
rection past  this  obstruction  until  traction  was  made 
upon  the  right  lobe  which  had  been  freed  from  its 
attachments  when  suddenly  a  prolongation  down- 
ward from  the  middle  lobe  came  up  from  its  location 
behind  the  sternum.  Immediately  the  patient  in- 
haled deeply  and  a  moment  later  she  spoke  of  the 
remarkable  relief  she  experienced. 

In  a  number  of  other  instances  I  have  observed  a 
similar  condition  to  a  less  marked  extent.  This  has 
been  observed  and  described  by  many  other  clinic- 


INDICATIONS    FOR    OPERATION  121 

ians  and  is  certainly  well  worth  bearing  in  mind  as  a 
strong  indication  for  surgical  treatment. 

In  other  instances  an  acute  inflammatory  enlarge- 
ment may  have  the  same  effect  only  usually  to  a 
more  marked  and  also  to  a  more  dangerous  extent 
because  of  the  cedematous  condition  of  the  surround- 
ing tissues. 

Here  again  the  course  of  the  disease  will  indicate 
the  treatment  that  should  be  chosen.  If  the  condition 
shows  a  tendency  to  subside  under  non-surgical  treat- 
ment the  latter  should  be  postponed  but  if  the  op- 
posite is  the  case  incision  of  the  gland  is  indicated. 
If  a  circumscribed  abscess  is  present  simple  incision 
will  cause  the  condition  to  subside.  If  the  inflam- 
matory condition  has  resulted  in  a  diffuse  inflam- 
mation it  may  become  necessary  to  remove  one 
lateral  or  one  lateral  end  and  the  median  lobe.  In 
this  case  it  will  become  necessary  to  perform  the 
operation  presently  to  be  described,  but  great  care 
must  be  taken  not  to  disturb  the  tissues  low  down 
in  the  neck  in  order  to  prevent  infection  of  the 
mediastinum  and  very  free  drainage  must  be  pro- 
vided for. 

The  abscess  of  the  thyroid  gland  may  be  located 
directly  underneath  the  anterior  capsule  of  the  gland 
when  it  will  be  reached  easily  by  making  an  incision 
parallel  with  and  along  the  inner  border  of  the  sterno- 
mastoid  muscle  over  the  most  prominent  portion  of 
the  swelling.  The  incision  must  be  carried  through 
the  skin,  superficial-fascia,  platysma  and  through  the 
capsule  of  the  gland.  If  the  abscess  is  in  the  super- 
ficial portion  of  the  gland  all  of  the  tissues  underneath 
the  skin  and  frequently  even  the  skin  will  be  found 


122  THYROID    GLAND 

to  be  oedematous  but  if  it  is  in  the  deep  portion  of 
the  gland  the  first  cedema  may  not  be  encountered 
until  the  capsule  of  the  gland  has  been  reached.  In 
one  instance  I  have  been  compelled  to  advance  more 
than  one  half  the  distance  through  the  gland  before 
pus  was  reached. 

The  patient,  a  woman,  twenty-six  years  of  age, 
who  had  previously  been  quite  normal  suddenly  ex- 
perienced severe  pain  in  the  region  of  the  right  lobe 
of  her  thyroid  gland.  When  seen  a  few  hours  later 
there  was  a  slight  amount  of  redness  and  very  slight 
swelling.  The  right  lobe  of  the  gland  was  exceeding- 
ly tender  but  there  seemed  to  be  no  grave  symptoms. 
Six  hours  later  severe  symptoms  of  asphyxia  ap- 
peared so  that  she  was  at  once  sent  to  the  hospital 
for  immediate  operation.  During  a  two  mile  ride 
symptoms  subsided  and  the  operation  was  postponed 
as  there  was  only  slight  difficulty  in  breathing.  The 
temperature  which  had  reached  103°  F.  remained 
below  100°  F.  the  leucocytosis  reached  26000  and 
the  general  appearance  of  the  patient  indicated  the 
presence  of  a  considerable  degree  of  sepsis.  On  the 
eleventh  day  after  the  beginning  of  the  attack  the 
patient  consented  to  an  incision  under  local  anaes- 
thesia with  1  per  cent,  cocaine  solution.  The  first 
pus  was  reached  after  more  than  one-half  of  the 
thickness  of  the  thyroid  gland  had  been  penetrated. 
Then  a  necrotic  area  3  c.  m.  wide  by  2  c.  m.  and 
5  c.  m.  deep  was  exposed,  filled  with  thick  yellow 
pus  and  necrotic  gland  tissue. 

One  interesting  feature  in  this  case  was  the  oc- 
currence of  severe  syncope  which  recurred  several 
times  each  day  during  the  fourth  and  sixth  days  after 


INDICATIONS    FOR    OPERATION  123 

the  beginning  of  the  attack  and  previous  to  the 
operation.  These  attacks  were  probably  due  to 
absorption  from  the  substance  of  the  necrotic  thyroid 
gland  together  with  pressure  upon  the  trachea  due 
to  the  abscess  and  to  pressure  from  the  surrounding 
codema.  After  carefully  swabbing  out  the  cavity 
of  the  abscess  and  inserting  a  gauze  drain  the  patient 
recovered  quite  as  readily  as  other  cases  in  which 
the  abscesses  were  located  more  superficially. 

Indication  for  Operation  in  Exophthalmic  Goi- 
tre. Aside  from  the  indications  just  described  in 
connection  with  the  treatment  of  simple  goitre  the 
following  indications  should  be  borne  in  mind  in 
connection  with  the  treatment  of  exophthalmic 
goitre. 

Whenever  improvement  in  these  cases  from  hy- 
gienic, dietetic  and  medicinal  treatment  together 
with  rest  is  only  of  temporary  duration  then  opera- 
tive treatment  is  strongly  indicated  because  in  these 
cases  the  prognosis  is  usually  most  excellent  if  the 
surgical  treatment  is  employed  before  the  patient  has 
suffered  too  many  recurrences,  while  the  fatal  con- 
clusion is  usually  only  a  matter  of  a  relatively  short 
time  depending  upon  the  frequency  and  severity  of 
the  attack  if  non-surgical  treatment  is  continued. 
Moreover,  the  recovery  after  surgical  treatment  will 
be  much  more  perfect  if  the  operation  is  performed 
before  the  heart  and  other  organs  have  suffered 
severely  by  these  recurrent  floodings  of  the  circula- 
tion with  thyroid  poison.  In  simple  goitre  it  is  not 
of  much  importance  except,  of  course,  in  the  presence 
of  asphyxia,  but  in  exophthalmic  goitre  the  element 
of  time  is  very  important. 


124  THYROID   GLAND 

Indication  for  Operation  in  Malignant  Growths  of 
the  Thyroid  Gland.  The  indications  for  the  re- 
moval of  thyroid  glands  containing  a  malignant 
growth  is  the  same  as  in  malignant  growths  in  other 
organs.  So  long  as  the  growth  seems  to  be  confined 
to  the  gland  so  that  it  seems  reasonably  safe  to  sup- 
pose that  it  will  be  possible  to  prevent  a  recurrence 
by  removing  the  entire  growth,  the  indication  is, 
of  course,  absolute.  I  have  never  encountered  this 
condition  except  in  cases  in  which  the  malignancy 
was  diagnosed  incidentally  during  the  microscopic 
examination  of  portions  of  glands  removed  for  other 
reasons. 

It  is  doubtful  whether  a  thyroid  gland  with  all 
lobes  involved  in  a  malignant  growth  can  ever  be 
removed  while  the  tumor  is  still  so  completely  con- 
fined to  the  gland  that  a  recurrence  can  be  prevented. 
If  the  tumor  is  confined  to  one  lobe  this  is  possible. 
In  these  cases  it  is  doubtful  whether  it  will  be  proper 
to  remove  the  entire  thyroid  gland  only  preserving 
the  parathyroids  or  whether  one  lobe  or  only  the 
upper  portion  of  one  lateral  lobe  should  be  left  in 
order  to  prevent  myxoedema. 

When  we  come  to  discuss  the  operative  technic  it 
will  be  shown  that  the  remarkable  arrangement  of 
the  blood  vessels  of  the  thyroid  gland  is  to  be  taken 
into  consideration  in  this  as  in  all  other  operations 
upon  this  organ.  Every  portion  of  each  lobe  seems 
to  be  connected  vascularly  with  every  portion  of 
the  other  lobes,  hence,  it  seems  doubtful  whether 
any  portion  may  be  left  safely  when  any  other  portion 
is  involved  in  a  malignant  growth. 


INDICATIONS    FOR    OPERATION  125 

In  removing  the  entire  gland,  however,  we  are 
certain  to  cause  myxoedema  unless  accessory  glands 
are  present  or  unless  this  condition  is  prevented  by 
transplanting  normal  thyroid  gland  into  the  body 
or  by  constantly  feeding  thyroid  glands  or  thyroid 
extract. 

All  of  these  facts  indicate  that  the  results  to  be 
expected  are  not  satisfactory.  On  the  other  hand, 
malignant  growths  of  the  thyroid  gland  may  pro- 
gress with  great  rapidity  and  destroy  the  life  of 
the  patient  in  a  few  months  or  they  may  cause  lit- 
tle distress  for  a  number  of  years.  I  have  person- 
ally encountered  both  forms.  I  would  consequently 
say  that  in  case  it  seems  possible  to  make  a  radical 
operation  when  the  patient  consults  the  physician, 
an  operation  should  be  performed  at  once.  If  it  is 
not  possible  to  do  this,  then  the  operation  should 
be  performed  only  if  it  becomes  necessary  in  order 
to  give  relief  from  pain  or  asphyxia. 

The  technic  of  the  operation  to  be  performed 
will  be  discussed  in  another  chapter. 

According  to  Salzer  the  transplantation  of  the 
thyroid  glands  is  so  likely  to  be  successful  into 
patients  who  have  been  entirely  deprived  of  their 
thyroid  glands  that  it  seems  reasonable  to  suggest 
the  removal  of  the  entire  gland  and  the  simultaneous 
transplantation  of  one  lobe  from  another  patient. 
The  transplantation  is  simple  and  accompanied  with 
so  little  shock  that  it  can  easily  be  accomplished 
at  the  same  time  at  which  the  complete  thyroidec- 
tomy is  performed  for  the  removal  of  the  malignant 
growth. 


CHAPTER  VIII. 


THYROIDECTOMY. 


In  describing  the  technic  of  this  operation  only 
those  methods  will  be  chosen  which  I  have  found 
reliable.  In  none  of  them  is  there  any  important 
feature  which  is  original  with  me.  Every  part  of 
every  operation  to  be  described  has  been  practiced 
by  other  surgeons  and  has  in  most  instances  been 
described  in  books  or  articles  in  scientific  journals. 
Most  of  the  important  features  were  developed  and 
practiced  by  Kocher  although  many  of  them  have 
been  modified  in  minor  details  by  others.  I  make 
this  statement  at  this  point  in  order  not  to  give  the 
impression  that  because  I  may  be  unduly  emphatic 
or  enthusiastic  in  the  discussion  of  certain  features 
that,  therefore,  these  may  be  my  original  methods. 
None  of  them  are  my  methods  except  by  adoption 
but  all  have  been  thoroughly  tested  by  me  in  many 
cases.  Those  who  have  faith  in  my  surgical  judgment 
in  selecting,  adapting  and  accepting  the  methods  of 
others  may  follow  these  methods  with  confidence. 

Incision.  It  is  important  to  bear  in  mind  the  fact 
that  in  operations  upon  the  thyroid  gland  the  in- 
cision must  be  so  planned  that  it  will  result  not  only 
in  a  proper  exposure  of  the  tissues  to  be  manipulated 
during  the  operation  but  also  to  result  in  little  or  no 
deformity  after  healing  has  taken  place.  It  is  very 
important  to  secure  free  access  to  the  tissues  to  be 


PLATE  II 


HORSE  SHOE  INCISION,  BEING  THE  TRANSVERSE  COLLAR  INCISION  OF 
KOCHER  EXTENDED  UPWARDS  AT  EACH  END  ALONG  THE  ANTERIOR  BORDER  OF 
THE  STERNO-MASTOID  MUSCLE  TO    (a)    AND    (b). 


THYROIDECTOMY  127 

manipulated  during  the  operation  because  as  will 
be  seen  later  there  are  various  important  structures 
which  must  be  protected  during  the  operation. 

Moreover,  it  is  important  not  to  traumatize  the 
tissues  of  the  thyroid  gland  itself  for  fear  of  producing 
hyperthyroidism.  It  is  also  important  to  have  a  clear 
view  of  the  field  of  operation  in  order  to  reduce  the 
loss  of  blood  to  a  minimum  because  aside  from 
the  loss  of  blood  itself  there  seems  to  be  a  cer- 
tain amount  of  harm  done  to  the  patient  if 
the  wound  surfaces  are  severely  saturated  with 
blood  during  the  operation,  because  according 
to  Kocher  there  is  a  certain  amount  of  specific 
toxicity  in  the  blood  in  these  cases.  The  total 
amount  of  traumatism  to  the  tissues  is  greatly 
reduced  if  an  ample  incision  gives  free  access  to  all 
tissues  to  be  manipulated.  This  is  even  of  greater 
importance  if  the  operation  is  performed  under  local 
than  under  general  anaesthesia,  because  the  skin  is 
most  easily  rendered  painless,  hence  a  large  incision 
causes  no  more  immediate  pain  than  a  small  incision, 
while  the  pain  of  the  remaining  steps  of  the  opera- 
tion is  proportionate  with  the  amount  of  trauma 
and  that  is  less  with  an  ample  than  with  a  small 
incision. 

As  all  of  the  muscles  of  the  neck  are  arranged  in 
pairs,  it  is  plain  that  every  incision  which  is  not 
symmetrical  as  regards  the  muscles  of  the  neck  must 
result  in  a  considerable  amount  of  deformity  because 
in  these  cases  aside  from  the  almost  imperceptible 
deformity  which  is  due  to  the  line  of  incision  itself 
all  of  the  deformity  resulting  from  thyroid  operations 
is  due  to  differences  in  the  muscles  on  both  sides  of 


128  THYROID   GLAND 

the  neck  which  can,  of  course,  be  avoided  if  the 
muscles  on  both  sides  are  always  treated  exactly 
alike.  This,  however,  is  possible  if  the  inverted 
horseshoe  incision,  Plate  2,  is  employed,  which  was 
introduced  by  Kocher  and  called  by  him  "the  collar 
incision." 

This  incision  begins  at  a  point  a  little  above  the 
level  of  the  most  prominent  portion  of  the  larynx 
and  the  anterior  border  of  the  sterno-cleido  mastoid 
muscle,  it  extends  downward  and  makes  a  regular 
curve  across  the  lower  border  of  the  thyroid  gland 
two  to  three  c.  m.  above  the  upper  margin  of  the 
sternum.  It  then  ascends  to  a  corresponding  point 
on  the  opposite  side  of  the  neck  making  a  perfectly 
uniform  symmetrical  line.  This  incision  may  be 
varied  in  length  and  in  the  distance  of  separation  of 
the  vertical  incisions  according  to  the  necessities  of 
the  case,  but  aside  from  these  variations  no  other 
incision  is  required  for  the  removal  of  any  portion  of 
the  thyroid  gland.  Many  other  incisions  have  been 
described  all  of  them  taking  the  anterior  edge  of  the 
sterno-cleido  mastoid  muscles  as  a  guide,  but  I  am 
thoroughly  convinced  that  except  for  the  opening 
of  abscesses  none  of  these  incisions  will  be  so  satis- 
factory as  the  one  just  described,  because  none  of 
them  give  so  perfect  an  approach  to  the  field  of  op- 
eration and  each  one  leaves  a  greater  amount  of 
deformity.  It  is  plain,  of  course,  that  in  many  cases 
it  will  not  be  necessary  to  make  the  incision  nearly 
so  long  as  shown  in  Plate  2.  If  the  tumor  is  con- 
fined to  the  middle  lobe  it  may  be  necessary  to 
make  an  incision  which  would  cover  no  more  than 
the  middle    one-third    of  this    incision.    But  even 


PLATE  III 


EXTERNAL  CAROTIQ.A.- 
INTERNAL  »  A.~ 
SUPERIOR  TMYROIDAr 
INTERNAL  JUGULAR^ 
COMMON  CAROTID  A.— 

VA6US.N. 

PHRENIC. N. 
THYROID  GLAND'. — 


STERNO  HYOID.M. 
OMO  "       M. 

STERNO  THYRCHDM, 
3TERNO  MASTOID^.! 


ANATOMICAL  DISSECTION  THROUGH  USUAL  INCISION  EMPLOYED  IN  MAK- 
ING THYROIDECTOMY,  EXHIBITING  STRUCTURES  TO  BE  CONSIDERED  DURING  THE 
OPERATION. 


THYROIDECTOMY  129 

in  this  case  the  curve  should  be  quite  as  sym- 
metrical and  the  tissues  underneath  should  be 
treated  precisely  the  same  on  both  sides  of  the  center 
of  the  incision.  Some  of  the  most  troublesome  little 
tumors  are  located  precisely  at  this  point  or  at  the 
very  lowest  portion  of  one  of  the  lateral  lobes,  and  in 
these  cases  it  is  well  not  to  permit  any  asymmetry  in  the 
skin  incision  because  an  avoidable  postoperative 
deformity  is  equally  annoying  to  the  surgeon  and 
to  the  patient. 

The  incision  is  carried  through  the  skin,  superficial 
fascia  and  platysma  myoides  muscle  and  all  of  these 
tissues  are  reflected  upwards  together  as  shown  in 
Plate  3,  leaving  the  entire  field  of  operation  thor- 
oughly exposed.  In  case  the  operation  is  performed 
under  local  anaesthesia  the  tissues  at  the  upper  angle 
of  the  wound  should  be  thoroughly  infiltrated  with 
the  anaesthetizing  solution  by  passing  a  blunt  needle 
attached  to  a  hypodermic  syringe  filled  with  this 
solution  along  the  anterior  and  posterior  surfaces  of 
the  sterno-cleido-mastoid  muscles  on  both  sides  and 
also  into  the  deep  tissues  along  the  lateral  wings  of 
the  thyroid  cartilage.  As  the  blunt  needle  enters 
these  various  spaces  the  anaesthetizing  fluid  is  slowly 
injected  and  again  as  the  needle  is  withdrawn,  the 
quantity  injected  being  in  inverse  proportion  to  the 
strength  of  the  solution  employed.  This  may  be 
done  before  the  primary  incision  is  made  by  first 
cocainizing  the  skin,  then  making  small  punctures 
with  a  sharp  scalpel  opposite  the  upper  extremities 
of  the  proposed  incision  and  then  passing  the  blunt 
needle  through  these  openings.  It  is  well  to  wait 
five  minutes  before  commencing  the  operation. 


130  THYROID    GLAND 

Having  exposed  our  field  of  operation  we  will  con- 
sider the  anatomical  structures  to  be  dealt  with  and 
to  be  protected  during  the  operation.  These  we  have 
illustrated  from  dissections  on  the  cadaver  adjusted 
to  the  various  steps  of  the  operation.  In  our  illustra- 
tions it  has  been  necessary  to  exaggerate  the  con- 
dition somewhat  in  order  to  secure  clearness,  but  all 
of  these  exaggerations  were  made  in  keeping  with 
the  actual  tissues  of  the  neck.  For  instance,  when 
the  sterno  thyroid  muscles  are  exposed  in  the  opera- 
tion they  are  covered  with  fascia,  but  if  this  were  left 
in  place  our  illustrations  would  not  be  more  effective 
than  are  photographs  made  during  this  stage  of  the 
operation  while  if  represented  as  showing  the  ex- 
posed muscle  fibres  the  reader  obtains  a  much  clearer 
idea  of  the  conditions. 

Anatomical  Consideration.  The  following  tissues 
must  be  borne  in  mind  throughout  the  operation 
in  order  to  accomplish  the  work  with  the  greatest 
possible  facility  in  the  shortest  time  with  the  least 
trauma,  and  without  injury  to  any  important  struc- 
tures and  with  the  prospect  of  the  best  possible 
cosmetic  results. 

The  gland  itself  is  normally  quite  small  weighing 
only  from  30  to  60  gms.  It  is  somewhat  smaller  in 
women  than  in  men  and  larger  relatively  in  infancy 
than  in  adult  life. 

The  diseased  gland  may  be  but  slightly  larger 
than  the  normal  gland,  sometimes  not  exceeding 
100  g.  while  it  may  be  many  times  this  size.  The 
largest  gland  I  have  personally  removed  weighed 
3,584  g.  after  the  blood  had  been  drained  out  of  it. 


THYROIDECTOMY  131 

This  would  make  the  gland  about  one  hundred  times 
the  normal  weight. 

In  considering  the  location  of  the  gland  itself  in 
relation  to  the  surrounding  structures  we  must  con- 
sequently bear  in  mind  not  only  the  normal  position 
and  the  normal  relations,  but  also  conditions  which 
are  the  results  of  the  change  in  form  of  the  gland  due 
to  irregularities  caused  by  the  pathological  condition 
present.  In  many  instances  abnormal  adhesions  are 
found  caused  by  the  previous  treatment  with  in: 
jections  into  the  gland  and  the  surrounding  tissues 
or  to  adhesions  caused  by  the  presence  of  infection 
at  some  previous  time.  Plate  3  represents  a  dissec- 
tion which  was  made  through  an  exposure  such  as 
one  obtains  by  making  the  collar  incision  shown  in 
Plate  2 .  It  has  seemed  better  to  represent  this  through 
the  same  incision  that  we  use  in  making  a  thyroid- 
ectomy than  through  the  ordinary  incision  employed 
in  the  dissecting  room,  because  in  this  way  we  have 
obtained  not  only  the  normal  relation  of  the  various 
structures  but  also  the  relation  of  these  structures 
to  the  wound  as  it  appears  in  the  actual  opera- 
tion. There  is  the  difference  of  having  freed  the 
muscles  of  their  fascia  and  having  carefully  exposed 
all  of  the  other  structures,  which  is  neither  necessary 
nor  desirable  in  the  actual  operation,  but  which  seems 
necessary  in  order  to  impress  sufficiently  the  relative 
positions  of  the  various  structures  which  must  be  con- 
stantly borne  in  mind  during  the  progress  of  the 
operation.  What  has  been  said  regarding  the  method 
of  producing  Plate  3  applies  also  to  Plates  4  and  5. 

On  the  right  hand  side  we  have  the  tissues  as  they 
appear  after  the  flap  has  been  dissected  up  together 


132  THYROID    GLAND 

with  the  platysma  myoides  muscle.  Of  these  muscles 
the  sterno-cleido-mastoid  muscle  will  be  borne  in 
mind  prominently  throughout  the  operation  because 
it  serves  as  a  guide  to  almost  every  important  step 
taken  as  will  be  seen  later  on  in  the  discussion  of  the 
technic.  The  other  three  muscles  are  treated  as  one 
structure  technically  throughout  the  various  opera- 
tions. When  displaced  by  retractors  these  muscles 
are  always  manipulated  as  one  object.  When  severed 
for  the  purpose  of  exposing  structures  they  are  again 
treated  as  one  structure  and  not  being  freed  of  the 
fascia  covering  these  tissues  the  operator  never 
distinguishes  them  as  separate  muscles.  On  the  left 
side  they  have  been  removed  entirely  in  order  to 
expose  the  underlying  structures  so  that  they  could 
be  drawn  distinctly  and  accurately.  In  the  operation 
itself  the  attachment  of  these  muscles  with  the  un- 
derlying structures  is  only  disturbed  so  far  as  the 
portion  of  the  gland  is  concerned  which  is  to  be  re- 
moved, all  of  the  other  attachments  remain  intact. 
So  long  as  the  surgeon  knows  precisely  where  these 
important  structures  are  located  it  is  quite  unneces- 
sary to  expose  them  by  dissection  in  order  to  protect 
them  against  injury,  but  it  is  of  the  greatest  import- 
ance primarily  to  know  where  these  various  struc- 
tures are  located  and  secondarily  to  carry  out  the 
steps  which  are  necessary  to  prevent  injury  which 
will  be  fully  described  later. 

The  thyroid  gland  itself  can  always  be  recognized 
readily  by  its  lobulated  surfaces.  It  is  an  exceed- 
ingly vascular  body.  In  the  living  body  it  has  a 
characteristic  purple  color  which  readily  distin- 
guishes  it   from   all   surrounding   structures.      The 


PLATE  IV 


THE   SAME   AS    PLATE   III,   WITH   THE  RIGHT  LOBE   OF  THE   THYROID   GLAND 
REMOVED   IN   ORDER  TO  BRING   OUT  THE  REMAINING    STRUCTURES. 


THYROIDECTOMY  133 

branches  of  the  superior  thyroid  artery  and  vein 
cover  the  upper  portion  of  the  gland  and  over  the 
surface  of  the  lower  portion  a  network  of  veins  com- 
municating with  both,  the  inferior  and  the  superior 
thyroid  veins  can  always  be  distinguished.  These 
veins  are  especially  prominent  in  cases  of  exophthal- 
mic goitre  but  they  can  always  be  seen  even  when 
there  is  little  or  no  enlargement  of  the  gland.  In 
order  to  make  the  drawing  more  distinct  only  the 
superior  thyroid  artery  is  shown  in  this  drawing, 
the  internal  jugular  vein  and  its  branches  having 
been  dissected  away  in  order  to  show  the  important 
deep  structures.  The  superior  thyroid  artery  can 
always  be  distinguished  during  the  operation  although 
its  origin  from  the  external  carotid  artery  is  but 
rarely  exposed  during  the  operation  and  the  internal 
carotid  artery  which  is  also  shown  in  Plate  3  should 
not  be  exposed  together  with  the  internal  jugular 
vein  when  the  surgeon  lifts  one  of  the  lobes  of  the 
gland  out  of  its  bed.  The  vagus  nerve  is  exposed 
occasionally  during  the  operation  especially  when 
there  are  enlargements  from  the  lateral  surface  of 
the  lateral  lobe.  Very  rarely  the  phrenic  nerve  is 
exposed  under  similar  conditions.  At  the  lower  end 
of  this  drawing  on  the  left  side  a  thin  white  line 
represents  the  recurrent  laryngeal  nerve.  As  will  be 
seen  later  it  is  not  necessary  to  expose  this  nerve 
during  the  operation,  but  in  this  instance  it  was 
exposed  for  a  short  distance  because  of  the  general 
dissection  which  was  employed  to  expose  the  other 
structures  which  have  just  been  described. 

In  Plate  4  the  internal  jugular  vein  has  been  left 
in  place  and  the  lobe  of  the  thyroid  gland  has  been 


134  THYROID    GLAND 

entirely  removed  not  as  it  would  be  removed  during 
an  operation  but  for  the  purpose  of  showing  the 
blood  supply  of  the  gland  which  must  be  considered 
during  every  operation  upon  this  gland  as  the  most 
important  factor.  On  the  right  hand  side,  the  draw- 
ing represents  the  same  structures  as  Plate  3  with  the 
addition  of  the  external  jugular  vein  which  may. 
however,  be  disregarded  technically  during  the  opera- 
tion. Usually  it  is  possible  to  make  the  incision  in- 
ternally to  this  vein  but  when  it  is  not  possible  to 
do  this,  the  latter  is  simply  caught  between  two 
pairs  of  forceps  and  ligated.  The  superior  thyroid 
vein  is  usually  located  somewhat  closer  to  the 
superior  thyroid  artery  than  shown  in  this  illustra- 
tion so  that  very  commonly  it  is  possible  to  ligate 
the  artery  and  the  vein  with  the  same  ligature  when 
making  thyroidectomy.  In  this  dissection  the  mus- 
cles represented  on  the  right  side  have  all  been  re- 
moved on  the  left  side  with  the  exception  of  the 
sterno-cleido-mastoid  which  has  been  reflected. 

In  Plate  5  we  have  represented  the  structures  in  a 
somewhat  more  diagramatic  form  in  order  to  give 
a  more  general  impression  of  the  tissues  to  be  borne 
in  mind.  On  the  left  side  all  of  the  muscles  shown  in 
Plates  3  and  4,  on  the  right  side  are  in  place  together 
with  the  external  jugular  vein,  while  on  the  right  side 
all  of  the  muscles  have  been  reflected  so  as  to  ex- 
pose virtually  all  of  the  tissues  which  are  to  be  con- 
sidered in  the  subsequent  technic.  Most  of  these 
structures  have  already  been  mentioned  in  connec- 
tion with  Plates  3  and  4  but  it  seems  worth  while  to 
consider  them  all  together  in  their  mutual  relations 
to  the  external  wound.    In  practice  one  is  but  rarely 


PLATE  V 


STERNO  HYOID  M.~ 
OMO  »       MA- 

STER NO  THYROID M 
MASTOID  M 

EXTERNALJU6ULARV. 


EXTERNAL  carot  ;-■ 

NTERNAL  CAROTID  A. 
SUPERIOR  TH  -'  =  : :  P 


1  A        "COMMON  CAROTID.  A. 

-^Ifi-HI                1 — PHRENICN. 

^^S^vNTERTiAL  J  UG  L 
^.W^f       '-?-?INFERIORTKYR0IDA' 

(    O'''^^^^^ 

I0%'' 

THYROID  GLAND 

!       RECURRENT 

LARYN6EALN. 

V 

pNEUMOQASTRIC.N. 

INFERIOR  THYROID.V. 
MIDDLE            "          V     . 

ANATOMICAL  DRAWING,  SOMEWHAT  DIAGRAMMATIC,  SHOWING  THE  MUS- 
CLES IN  PLACE  ON  THE  RIGHT  SIDE  AND  ALL  OF  THE  OTHER  ANATOMICAL 
STRUCTURES  TO  BE  CONSIDERED  IN   PLACE  ON  THE  LEFT  SIDE. 


PLATE  VI 


INCISION  FOR  THYROIDECTOMY,  WITH  SKIN  SUPERFICIAL  FASCIA  AND 
PLATYSMA  RETRACTED  UPWARD  AND  HELD  OUT  OF  THE  WAY  WITH  RETRACTOR 
(i).  HAEMOSTATS  ON  SEVERED  VESSELS  AXD  SHADOWS  SHOWING  LARGE 
BRANCHES   OF   ANTERIOR   JUGULAR   VEIN. 


THYROIDECTOMY  135 

called  upon  to  operate  in  cases  in  which,  the  relative 
size  of  the  thyroid  gland  and  the  other  structures 
is  as  it  is  shown  in  this  figure,  which  is  approximately 
as  it  exists  in  the  normal  conditions,  but  this  will 
show  how  the  different  structures  appear  normally 
and  then  one  can  judge  the  changes  from  the  amount 
of  deformity  encountered  in  each  individual  case. 
The  enlarged  portion  of  the  gland  usually  simply 
displaces  the  various  structures  by  lateral  pressure 
but  occasionally  these  structures  are  overlapped  by 
some  projection  from  the  gland.  There  is,  of  course, 
an  infinite  variety  of  these  displacements  so  that  it 
would  be  useless  to  describe  the  individual  forms 
which  have  been  or  may  be  encountered.  These 
drawings  may  be  recommended  for  careful  study, 
and  may  be  verified  in  the  cadaver  with  profit  be- 
fore attempting  the  operation.  As  the  condition  is 
very  similar  in  the  cat  and  in  the  dog  it  is  wise  to 
operate  upon  these  animals  before  attempting  to 
perform  the  operation  upon  the  human  patient. 

When  one  has  once  become  practically  familiar 
with  the  anatomical  structures  just  described,  the 
technic  which  follows  will  acquire  a  much  less  com- 
plicated aspect  from  that  which  one  would  obtain 
without  this  familiarity.  Although  it  is  true  that 
most  of  the  danger  to  the  patient  comes  from  the 
fact  that  operations  upon  the  thyroid  gland  are  per- 
formed upon  patients  who  would  not  be  good  sub- 
jects for  any  operation,  still  the  local  conditions  are 
such  that  the  danger  from  the  operation  will  be 
greatly  increased  unless  the  surgeon  is  perfectly 
familiar  with  the  structures  described  in  Plates  4  and 


136  THYROID    GLAND 

5,  which  will  be  referred  to  throughout  the  discus- 
sion of  the  various  steps  of  surgical  technic. 

Plate  6  represents  the  flap  of  the  skin  together  with 
the  platysma  myoides  reflected  upwards.  A  number 
of  veins  which  are  located  immediately  underneath 
the  skin  are  so  small  in  the  normal  conditions  that 
they  will  not  require  any  attention  in  operations  upon 
the  neck  but  are  so  large  in  patients  suffering  from 
goitre  that  they  bleed  very  freely.  These  should  be 
grasped  at  once  with  haemostatic  forceps  which  may 
be  left  in  place  as  they  do  not  interfere  with  the 
subsequent  steps  of  the  operation.  Occasionally 
there  is  some  bleeding  from  the  under  surface  of  the 
flap  which  should  be  controlled  by  hasmostatic  for- 
ceps and  ligatured  at  once.  The  edges  of  the  sterno- 
cleido-mastoid  muscles  can  be  seen  on  either  side, 
and  over  the  surface  underneath  the  fascia  there  are 
usually  several  large  veins  as  indicated  by  the  shaded 
lines  in  this  figure.  These  may  extend  longitudinally 
over  the  surface  of  the  gland  parallel  to  each  other 
or  they  may  form  a  network.  They  are  usually 
branches  of  the  anterior  jugular  vein.  It  is  also  pos- 
sible to  see  the  sternohyoid  and  the  sternothyroid  and 
occasionally  a  portion  of  the  edge  of  the  omohyoid 
muscles  through  the  fascia  as  shown  in  this  figure. 

The  anterior  horseshoe  shaped  flap  is  held  out  of 
the  way  throughout  the  operation  by  means  of  the 
retractor.  It  is  well  to  fasten  the  towels  to  the  skin 
by  means  of  a  safety  pin  as  shown  in  this  figure  in 
order  to  prevent  them  from  slipping  up  and  down 
over  the  edge  of  the  wound  during  the  operation. 

Plate  7  represents  the  same  conditions  as  Plate  6 
with  the  addition  of  illustrating  an  important  step 


PLATE  VII 


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.THE  SAME  AS  PLATE  VI,  WITH  KOCHEK  DIEECTOE  (b)  INSEBTED  UNDEB- 
NEATH  ANTEEIOK  JUGULAB  VEIN  WITH  TWO  HAEMOSTATIC  FOECEPS  (a)  AND 
(A')    APPLIED. 


PLATE  VIII 


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THE  SAME  AS  PLATE  VII,  WITH  LONG-JAWED  KOCHER  HAEMOSTATIC  FOR- 
CEPS APPLIED  TO  STERNO-HYOID,  STERNO-THYROID  AND  OMO-HYOID  MUSCLES 
IN   FRONT  OF  THE  RIGHT  LOBE   OF   THE   THYROID  GLAND. 


THYRODECTOMY  137 

in  the  operation.    In  order  to  keep  the  wound  con- 
stantly free  from  blood  Kocher  has  introduced  a 
grooved  director  represented  at  (b)  with  its  point  in- 
serted underneath  the  anterior  jugular  vein.  In  order 
to  expose  the  vein  the  fascia  overlying  it  is  split 
longitudinally  and  then  it  is  lifted  up  by  means  of 
the  blunt  pointed  end  of  the  Kocher  director.    Two 
haemostatic  forceps,   preferably  of  the  type  intro- 
duced by  Kocher  and  shown  at  (a)  are  applied  to 
the  vessel  as  indicated  in  this  figure  and  then  it  is 
severed  over  the  middle  of  the  director.    It  is  well 
to  ligate  both  ends  of  the  vessels  at  once  in  order  to 
keep  the  surface  free  from  instruments  for  the  con- 
venience of  the  subsequent  steps  of  the  operation. 
This  leaves  the  sternohyoid,  the  sternothyroid,  the 
omohyoid  and  the  edge  of  the  sterno-cleido  muscles 
exposed.   All  haemorrhage  has  been  controlled  either 
by  the  application  of  haemostatic  forceps  which  are 
still  in  place  or  by  clamping  and  ligating.    In  most 
cases  it  will  be  necessary  to  apply  two  pair  of  forceps 
to  the  muscles  covering  the  anterior  surface  of  the 
gland  as  shown  at  (b)  and  (V)  Plate  8.    These  forceps 
should  again  be  of  the  type  shown  in  this  illustration 
which  were  introduced  by  Kocher.    They  should  be 
placed  about  2  c.  m.  apart  and  parallel  with  each 
other  and  closed  just  tightly  enough  to  stop  all 
haemorrhage  but  not  sufficiently  tightly  to  crush  the 
muscle.    It  is  usually  best  to  ligate  the  veins  caught 
in  forceps  (a)  and  (a")  before  the  present  step  of  the 
operation  is  taken  because  slight  traction  upon  these 
forceps  sometimes  causes  a  tear  in  the  thin  walls  of 
these  veins  which  gives  rise  to  quite  a  severe  haemorr- 


138  THYROID    GLAND 

hage,  and  which  may  seriously  obscure  the  subse- 
quent steps  of  the  operation. 

The  muscle  is  then  cut  transversely  and  the  handles 
of  the  forceps  are  turned  back  as  indicated  at  (b) 
and  (b")  which  results  in  the  perfect  exposure  of 
the  entire  anterior  surface  of  one  lobe  of  the  thyroid 
gland  as  shown  in  Plate  9.  The  same  step  will  usually 
have  to  be  repeated  on  the  opposite  side,  although  it 
is  sometimes  possible  to  obtain  a  sufficiently  free 
exposure  by  simply  retracting  the  muscles  on  the 
opposite  side.  Forceps  (c)  and  (c")  are  now  applied 
precisely  as  (b)  and  (b")  were  in  Plate  8,  so  as  not  to 
interfere  with  the  nerve  supply  of  the  muscles,  and 
the  muscles  are  severed  transversely  half  way  be- 
tween these  two  forceps.  When  these  are  turned 
back  to  correspond  with  (b)  and  (b")  which  are  at- 
tached to  the  corresponding  muscles  on  the  opposite 
side  the  anterior  surface  of  the  entire  thyroid  gland 
is  perfectly  exposed  as  shown  in  Plate  10. 

There  are  several  advantages  in  turning  both  of 
these  muscles  back.  It  facilitates  the  operation  be- 
cause with  so  free  an  exposure  the  remaining  steps 
of  the  operation  can  be  accomplished  so  much  more 
rapidly  that  in  many  cases  it  is  really  worth  while. 
It  requires  only  a  moment  to  re-unite  the  muscles. 
Moreover,  there  is  an  advantage  in  treating  both  sides 
alike  because  of  the  resulting  symmetry  when  the 
operation  is  completed.  Again  the  amount  of  trauma- 
tism to  the  tissues  will  be  reduced  by  having  free 
access  to  the  gland.  In  case  the  smaller  lobe  contains 
nodules  of  diseased  tissues  these  will  be  discovered 
and  can  readily  be  removed.  In  many  instances  a 
more  thorough  operation  will  be  performed  if  both 


PLATE  IX 


5w 


/ 


/ 


N 


THE  SAME  AS  PLATE  VIII,  WITH  THE  MUSCLES  CUT  ACROSS  BETWEEN  FOR- 
CEPS  (B)  AND  (b')  ON  THE  RIGHT  SIDE  AND  SIMILAR  FORCEPS  (c)  AND  (c') 
APPLIED   TO  THE  MUSCLES  OF  THE  LEFT   SIDE. 


PLATE  X 


</ 


s?3    .       V      7*  it.         / 


THE  SAME  AS  PLATE  IX,  WITH  THE  MUSCLES  ALSO  CUT  TEANSVERSELY 
ON  THE  EIGHT  SIDE  BETWEEN  FORCEPS  (c)  AND  (c'),  EXPOSING  THE  AN- 
TEEIOE  SUEFACE   OF  THE  GLAND  PERFECTLY. 


THYROIDECTOMY  139 

lobes  are  exposed  because  of  the  ease  with  which  it  is 
possible,  under  these  conditions,  to  ligate  the  in- 
ferior thyroid  artery  and  vein  on  the  side  on  which 
the  lobe  is  smaller.  It  may  be  well  to  advise  this  ad- 
ditional step  to  those  who  have  not  yet  obtained  a 
great  amount  of  experience  in  this  field  of  operation. 
With  increased  experience  one  acquires  the  ability 
to  work  with  less  perfect  exposure. 

Plate  1 0  shows  a  perfect  exposure  of  both  lobes  of 
the  thyroid  gland  with  the  right  lobe  somewhat  en- 
larged. The  form  of  retractor  shown  in  Plates  2,  3 
and  4  is  very  convenient  for  exposing  the  field  of 
operation.  Forceps  (b),  (b')  and  (c)  and  (c')  serve 
the  double  purpose  of  preventing  haemorrhage  from 
the  cut  ends  of  the  muscles  overlying  the  gland  and 
that  of  very  convenient  retractors.  Two  precautions 
must  be  borne  in  mind.  These  forceps  must  not  be 
closed  too  firmly  but  just  sufficiently  to  prevent 
haemorrhage  in  order  not  to  injure  the  structure  of  the 
muscles,  and  assistants  must  not  pull  too  heavily 
upon  them  during  the  operation.  A  portion  of  the 
muscle  at  least  half  a  c.  m.  in  width  must  be  left 
projecting  beyond  the  forceps  in  order  to  preserve 
perfectly  smooth  cut  surfaces  for  suturing  when 
the  operation  upon  the  gland  itself  has  been  com- 
pleted. 

The  branches  of  the  two  superior  thyroid  arteries 
communicate  very  freely  with  each  other  which 
can  be  demonstrated  easily  on  injected  specimens 
but.  even  in  the  living  body  it  is  apparent  from  the 
arrangement  of  these  branches  that  this  must  be 
the  case.  At  the  upper  end  a  narrow  band  extends 
upwards  in  front  of  the  larynx,  and  is  attached  to  the 


140  THYROID    GlyAND 

upper  edge  of  the  thyroid  gland.  This  structure  is 
usually  present  and  represents  the  remnant  of  the 
duct  which  communicates  between  the  gland  and 
the  oesophagus  during  foetal  life.  Occasionally  the 
duct  persists  but  this  is  very  rare.  Usually  it  is 
simply  a  small  band  of  connective  tissue  which  may 
be  clamped  between  two  pair  of  hemostatic  forceps, 
cut  and  ligated. 

In  many  cases  it  is  possible  to  retract  the  sterno- 
thyroid, sterno-hyoid  and  omo-hyoid  muscles  as 
shown  in  Plate  1 1 ,  without  clamping  and  cutting  them. 
This  may  be  done  on  both  sides  of  the  median  line 
either  simultaneously  or  successively.  Some  opera- 
tors with  great  skill  and  much  experience  make  this 
their  typical  operation  and  choose  the  method  shown 
in  Plates  8,  9  and  10,  only  in  cases  in  which  for  any 
other  reason  it  does  not  seem  possible  to  complete 
the  operation  without  taking  this  additional  step. 
It  is  often  especially  difficult  to  dislocate  the  enlarged 
lobe  forward  if  these  muscles  are  left  intact.  One 
also  may  experience  difficulty  in  controlling  the 
bleeding  from  the  small  veins  which  may  be  torn  in 
bringing  forward  the  lobe.  The  ligation  of  the  in- 
ferior thyroid  vessels  on  the  opposite  side  from  the 
one  on  which  the  lobe  has  been  removed  is  also  very 
much  more  difficult  if  these  muscles  are  left  intact. 
There  is  a  marked  difference  in  the  strength  and 
elasticity  of  these  muscles  in  different  patients  and 
consequently  it  is  well  to  treat  each  case  according 
to  the  conditions  found  after  making  a  longitudinal 
separation  of  the  muscles  of  both  sides.  This  is 
usually  best  accomplished  by  means  of  dissecting 
forceps  and  scalpel.   Separating  the  posterior  surface 


PLATE  XI 


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THE    SAME    AS     PLATE    X,    WITH    THE    MUSCLES     COVERING    THE    THYROID 
GLAND  RETRACTED  BY  RETRACTORS    (2)    AND    (3)    INSTEAD  OF  BEING    SEVERED. 


PLATE  XII 


SHOWS  THE  SUPERIOR  THYROID  ARTERY  ON  THE  RIGHT  SIDE  RAISED  ON 
THE  POINT  OF  A  GROOVED  DIRECTOR  (f)  AND  CLAMPED  WITH  HAEMOSTATIC 
FORCEPS  (E)  AND  (E'),  WHILE  ON  THE  OTHER  SIDE  THE  VESSEL  HAS  ALREADY 
BEEN   SEVERED  AND  IS  HELD  BY  FORCEPS    (e")    AND    (e'"). 


THYROIDECTOMY  141 

of  the  muscle  from  its  attachment  to  the  thyroid 
gland  is  best  accomplished  by  passing  the  index 
finger  between  the  anterior  surface  of  the  gland  and 
the  posterior  surface  of  the  muscles  on  either  side. 

In  doing  this  it  is  best  to  apply  the  greater  amount 
of  pressure  anteriorly  against  the  posterior  surface 
of  the  muscles  in  order  not  to  traumatize  the  sub- 
stance of  the  thyroid  gland.  This  step  of  the  opera- 
tion is  only  rarely  accompanied  with  haemorrhage 
which  can  be  controlled  at  once  with  haemostatic 
forceps.  The  anterior  surface  of  the  gland  is  always 
covered  with  a  perfect  network  of  large  thin-walled 
veins  which  should  not  be  injured  because  they 
bleed  very  freely  and  cover  the  field  with  so  much 
blood  that  the  remaining  steps  of  the  operation  will 
be  greatly  retarded. 

Plate  12  shows  the  same  exposure  as  Plate  10.  The 
haemorrhage  has  been  completely  controlled  by  the 
application  of  haemostatic  forceps  to  all  of  the  smaller 
bleeding  points  and  by  applying  two  haemostatic 
forceps  to  each  one  of  the  larger  vessels  before  cutting 
them  and  then  ligating  them  at  once.  With  the  gland 
fully  exposed  the  actual  steps  for  the  removal  of  the 
gland  may  be  commenced.  A  Kocher  director  is 
passed  underneath  the  superior  thyroid  artery  and 
vein  either  separately  as  shown  at  Plate  12,  or  the 
two  vessels  may  be  taken  together.  After  the  end  of 
the  director  has  been  passed  through  underneath 
one  or  both  of  these  vessels  two  pair  of  haemostatic 
forceps  (e)  and  (e')  are  clamped  upon  this  vessel  and 
then  the  latter  is  severed  over  the  director  between 
these  forceps.  The  cut  ends  of  these  vessels  are  then 
turned  up  as  shown  at  (e")  and  (e" ')  and  ligated  at 


142  THYROID   GLAND 

once.  Usually  the  superior  thyroid  vessels  can  be 
treated  in  this  manner  between  their  origin  from  the 
external  carotid  artery  and  their  distribution  to  the 
gland  but  occasionally  these  vessels  divide  into 
various  branches  early  and  then  it  will  become  neces- 
sary to  ligate  two  or  more  branches  separately. 

Only  in  rare  cases  do  we  find  it  necessary  to  ligate 
the  superior  thyroid  vessels  on  both  sides  in  the  same 
patient.  It  is  much  more  common  to  ligate  one  super- 
ior and  both  inferior  thyroid  vessels  in  the  same  case. 
In  case  it  seems  advisable  to  ligate  the  superior 
thyroid  vessels  on  both  sides  it  seems  best  to  follow 
the  method  of  Jacobson  to  be  described  fully  later. 

After  the  superior  thyroid  vessels  have  been 
clamped,  cut  and  ligated  on  one  side  it  is  possible 
to  dislocate  the  enlarged  lobe  of  the  thyroid  gland 
forward,  a  method  first  introduced  by  Kocher  and 
called  "luxation  of  the  thyroid  gland." 

The  steps  that  have  just  been  described  and  which 
have  been  illustrated  in  Plate  12,  may  be  accomplished 
without  cutting  the  muscles  covering  the  anterior 
surface  of  the  thyroid  gland.  This  is  shown  in  Plate 
13.  There  is,  however,  much  less  space  and  if  the 
operation  is  under  local  anaesthesia  the  patient 
suffers  greatly  from  the  necessary  pulling  upon  the 
retractors  (3)  and  (3')  and  (2)  and  (2')  as  shown  in 
Plate  13.  Unless  the  enlargement  is  confined  to  the 
middle  lobe  or  is  only  moderately  large  in  one  of 
the  lateral  lobes  it  seems  better  when  operating  under 
local  anaesthesia  to  secure  the  exposure  of  the  gland 
indicated  in  Plate  12. 

In  Plate  14  the  step  which  should  have  been  com- 
pleted in  Plates  12  and  13  of  severing  the  superior 


PLATE  XIII 


REPRESENTS  THE  SAME  STAGE  OF  THE  OPERATION  AS  PLATE  XII,  WITH 
THE  MUSCLES  NOT  SEVERED  BUT  RETRACTED  BY  INSTRUMENTS  AT  (2)  AND 
(2')     AND     (3)     AND    (3'). 


PLATE  XIV 


THE   RIGHT   LOBE  OF   THE  GLAND   HAS   BEEN   LOOSENED    FROM    ITS   ATTACH- 
MENTS  TO  THE  TISSUES  EXTERNAL  TO  IT  AND  HAS  BEEN   DISLOCATED  FORWARD. 


THYROIDECTOMY  143 

thyroid  vessels  is  represented  as  being  under  way. 
The  Kocher  director  (f)  is  represented  as  elevating 
the  superior  thyroid  vein  and  the  haemostatic  forceps 
(e)  and  (e')  have  been  clamped  upon  this  vessel  on 
either  side  of  the  director.  The  right  lobe  of  the  gland 
has  been  dislocated  forward  so  that  it  now  rests 
upon  the  haemostatic  forceps  and  retractors  which 
appear  in  the  previous  figures  on  the  surface. 

It  is  possible  in  many  cases  to  carry  out  this  step 
of  the  operation  before  severing  the  superior  thyroid 
vessels,  but  there  is  no  advantage  in  doing  this  while 
there  are  several  distinct  advantages  in  first  ligating 
and  severing  the  superior  thyroid  vessels  and  then 
dislocating  the  gland  forward.  In  this  way  the  ten- 
sion is  removed  from  these  vessels  and  the  vein 
especially  is  protected  against  injury  by  traction. 
The  manipulations  may  press  some  thyroid  secretion 
into  the  circulation.  The  anterior  jugular  vein  has  also 
been  severed  early  during  the  operation  and  this  will 
be  of  advantage  to  the  patient  in  the  same  direction. 
Occasionally  there  is  some  haemorrhage  from  the 
small  vessels  which  are  torn  when  the  gland  is  luxated, 
and  if  the  superior  thyroid  vessels  have  already 
been  disposed  of  it  is  much  easier  to  control  this 
bleeding  either  by  pressure  or  by  clamping  with 
forceps  than  if  they  have  not,  because  much  space  is 
gained  in  this  manner.  The  luxation  can  usually  be 
accomplished  readily  by  passing  the  index  finger  be- 
tween the  gland  and  the  connective  tissue  capsule 
and  passing  it  from  above  downward  at  the  same 
time  lifting  the  gland  forward. 

In  freeing  the  gland  from  the  surrounding  tissues 
it  is  again  important  to  direct  the  pressure  of  the 


144  Thyroid  gland 

finger  away  from  the  gland  instead  of  pressing  to- 
ward the  gland  in  order  not  to  traumatize  the  gland 
for  fear  of  pressing  thyroid  secretion  into  the  circu- 
lation thus  causing  post-operative  hyper-thyroidism. 
Many  surgeons  prefer  not  to  luxate  the  gland  in 
this  manner,  but  to  dissect  the  entire  gland  free  from 
its  attachment  by  sharp  dissection  with  scalpel  and 
dissecting  forceps,  laying  bare  all  of  the  tissues, 
notably  the  inferior  thyroid  vessels  and  the  recurrent 
laryngeal  nerve.  Landstrdm  goes  no  further  than 
this  with  his  concise  dissection  and  prevents  injury 
to  the  parathyroid  glands  by  leaving  the  posterior 
capsule  and  a  thin  portion  of  thyroid  gland  tissue  in 
place  while  a  few  authors  go  so  far  as  to  demand  that 
the  dissection  must  locate  not  only  these  structures 
but  also  the  inferior  parathyroid  gland  on  the  side 
from  which  the  lobe  is  to  be  removed.  It  seems  quite 
plain  that  it  is  quite  unnecessary  to  expose  the 
patient  to  the  prolonged  operation  which  is,  however, 
of  much  greater  harm  if  the  patient  is  kept  under 
general  anaesthesia  during  this  period  of  time  than 
if  local  anaesthesia  is  employed.  All  of  the  steps 
which  have  just  been  described  can  be  carried  out  in 
some  patients  through  a  field  of  operation  as  indi- 
cated in  Plate  1 5  in  which  the  muscles  have  been  re- 
traced but  not  severed.  The  luxation  of  the  gland 
is  especially  difficult  in  cases  in  which  there  has  ex- 
isted an  inflammation  of  the  gland  or  a  parathyroid- 
itis  or  those  in  which  the  gland  has  been  punctured 
by  hypodermic  needles  for  the  injection  of  various 
substances.  Cases  that  have  been  treated  with  x-ray 
or  with  electricity  seem  to  be  especially  vascular  and 
it  is  often   difficult  to  stop  the  haemorrhage  after 


PLATE  XV 


t 


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M 


A'  V^S 


THE   SAME   AS   PLATE   XIV,    WITH   THE    MUSCLES    RETRACTED   AND   NOT   SEV- 


PLATE  XVI 


THE  SUPERIOR  THYROID  VESSELS  HAVE  BEEN  LIGATED  DOUBLE  AND  CUT, 
THE  RIGHT  LOBE  HAS  BEEN  ENTIRELY  FREED  AND  DISPLACED  FORWARD,  THE 
INFERIOR  THYROID  VESSELS  ARE  ISOLATED  AND  HELD  ON  POINT  OF  KOCHER 
DIRECTOR    (N)    AND  CAUGHT  BY   TWO   PAIRS   OF  FORCEPS    (m)    AND    (m'). 


THYROIDECTOMY  145 

luxating  the  gland.  There  may  simply  be  diffuse 
general  oozing  without  any  haemorrhage  from  vessels 
of  considerable  size.  Usually  tamponing  with  gauze 
into  the  cavity  out  of  which  the  gland  has  been  lifted 
will  suffice  to  stop  this  bleeding.  It  is  well  to  apply 
this  gauze  tampon  immediately  upon  lifting  forward 
the  gland  and  to  leave  it  in  place  during  the  time 
required  for  completing  the  remaining  steps  of  the 
operation.  Occasionally  it  may  become  necessary 
to  pass  a  few  catgut  sutures  over  some  of  the  oozing 
surfaces.  In  this  case  it  is  important  to  bear  in  mind 
the  proximity  of  the  anatomical  structures  shown 
in  Plates  3,  4  and  5.  It  is  possible  to  injure  the  in- 
ternal .  jugular  vein  during  these  manipulations  es- 
pecially in  cases  in  which  there  are  strong  adhesions 
due  to  parathyroid  infection  some  time  previous 
to  operation. 

In  order  to  make  these  dangers  more  apparent  we 
have  represented  in  Plates  16  and  17  the  carotid 
artery,  the  jugular  vein  and  the  pneumogastric 
nerves  as  they  would  appear  were  a  clear  dissection 
made.  In  the  operation  upon  the  living  patient,  these 
structures  never  appear  so  clearly  as  here  represented 
although  they  can  be  readily  distinguished,  the  artery 
especially  by  its  pulsation  and  the  vein  by  its  increase 
and  decrease  in  size  during  inspiration  and  expiration. 

Under  the  actual  conditions  a  gauze  tampon  is 
packed  between  these  vessels  and  the  gland  which 
has  been  lifted  forward  -and  pushed  over  to  the  op- 
posite side  but  as  this  would  cover  up  the  portion 
it  is  desirable  to  show,  it  has  been  left  out  of  the 
drawing.  Upon  lifting  up  the  lobe  of  the  gland  and 
pushing  it  over  to  the  opposite  side  it  is  possible  to 


146  THYROID    GLAND 

locate  the  inferior  thyroid  vessels  as  shown  in  Plate 
16.  A  Kocher  director  is  placed  under  one  or  both 
of  these  vessels,  as  in  Plate  16,  and  haemostatic  forceps 
are  applied  to  their  side  as  shown  at  (m)  and  (m'). 
Usually  the  inferior  thyroid  artery  and  vein  are 
farther  apart  than  shown  in  Plate  16,  and  must  be 
lig  ated  separately,  and  most  commonly  bifurcation 
takes  place  at  a  point  to  the  outside  of  the  portion 
grasped  by  the  haemostatic  forceps  so  that  several 
forceps  are  required  and  several  ligatures  have  to  be 
employed. 

Plate  17  shows  the  same  steps  of  the  operation  il- 
lustrated in  Plate  16  without  section  of  muscles.  It 
is  often  very  difficult  to  expose  the  inferior  thyroid 
vessels  under  these  conditions  because  all  of  these 
muscles  have  their  lower  attachment  to  the  sternum 
and  their  upper  attachments  are  very  much  farther 
apart  than  the  lower  ones,  consequently  one  en- 
counters most  difficulty  during  manipulations  which 
must  be  made  in  the  lower  portion  of  the  field  of 
operation. 

In  comparing  the  relation  of  the  inferior  thyroid 
vessels  in  Plate  17  with  those  represented  in  Plate  5, 
it  becomes  apparent  that  the  point  of  the  forceps 
marked  (m)  is  dangerously  near  the  point  where  the 
recurrent  laryngeal  nerve  crosses  the  inferior  thyroid 
artery.  As  mentioned  before  in  the  discussion  of 
Plates  3  and  5  it  was  pointed  out  that  the  recurrent 
laryngeal  nerve  is  a  very  fine  thread-like  structure 
which  can  easily  be  located  in  a  dissection  whose 
object  it  is  to  expose  this  nerve  either  in  the  living 
body  or  in  the  cadaver,  and  many  surgeons  insist 
upon  making  this  demonstration  in  every  case  dur- 


PLATE  XVII 


THE  SAME  AS  PLATE  XVI,  WITH  THE  MUSCLES  NOT  CUT  BUT  HELD  OUT  OF 
THE  WAY  BY  RETRACTORS    (2)    AND    (3). 


PLATE  XVIII 


SHOWS  THE  EIGHT  LOBE  ENTIRELY  FREE,  WITH  ITS  POSTERIOR  CAPSULE 
(P.)  AND  A  PORTION  OF  THE  GLAND  IN  THE  FORM  OF  A  THIN  LAYER  OF  THE 
POSTERIOR  PORTION   OF  THE  LOWER  END   OF  THE  LOBE  LEFT  IN   PLACE. 


THYROIDECTOMY  147 

ing  the  operation  and  before  ligating  the  inferior 
thyroid  artery  or  its  branches  in  order  that  no  harm 
may  come  to  the  recurrent  laryngeal  nerve  during 
the  operation.-  It  is  most  important  for  every  sur- 
geon who  performs  thyroidectomy  to  expose  this 
nerve  repeatedly  either  in  the  cadaver  or  in  the 
living  body  in  order  to  be  quite  positive  as  to  its 
location,  but  once  having  become  familiar  thus,  it 
seems  far  better  to  plan  the  operation  so  that  this 
tedious  dissection  may  be  avoided,  provided  the 
operation  can  be  performed  with  the  same  safety  to 
the  patients.  Fortunately  this  nerve  is  so  located 
that  it  can  always  be  avoided  if  the  entire  lower  half 
of  the  posterior  capsule  of  the  thyroid  gland  is  left 
undisturbed  in  its  attachment  to  the  anterior  sur- 
face of  the  trachea.  The  same  plan  accomplishes 
the  protection  of  the  lower  parathyroid  gland  which 
is  still  more  intimately  attached  to  the  posterior 
surface  of  the  thyroid  gland  than  is  the  case  with  the 
recurrent  laryngeal  nerve. 

In  Plate  18  this  step  of  the  operation  has  been  illus- 
trated. The  letter  (r)  represents  the  posterior  capsule 
together  with  a  layer  of  the  posterior  portion  of  the 
thyroid  gland  which  has  also  been  left  in  place  be- 
cause the  parathyroid  gland  some  times  is  situated 
between  some  of  the  posterior  lobules  of  the  thyroid 
gland  and  by  leaving  this  layer  one  is  perfectly 
certain  to  leave  the  parathyroids  undisturbed. 

The  forceps  (g)  and  (gr)  are  attached  to  the  in- 
ferior thyroid  vein  which  enters  the  thyroid  gland 
from  its  posterior  surface,  the  gland  being  inverted 
by  being  folded  forward  over  the  opposite  lobe,  its 
attachment  to  the  isthmus  forming  the  hinge  upon 


148  THYROID    GLAND 

which  the  lobe  is  swung.  The  exposed  portion  of  the 
inferior  thyroid  artery  and  vein  is  somewhat  longer 
than  is  usually  encountered,  but  it  was  difficult  to 
represent  it  more  nearly  in  its  exact  form.  Frequently 
one  encounters  an  artery  of  considerable  size  enter- 
ing the  gland  at  a  point  a  little  below  the  point  in 
the  posterior  capsule  marked  (r) .  This  is  the  middle 
thyroid  artery  which  is  usually  not  recognized  until 
it  has  been  severed.  It  must  then  be  caught  with 
haemostatic  forceps  and  ligated.  It  is  well  to  apply 
these  forceps  very  carefully  because  by  grasping  too 
much  tissue  in  the  bite  of  the  forceps  it  is  possible  to 
include  the  recurrent  laryngeal  nerve  causing  a  pa- 
ralysis of  the  vocal  cord.  The  bleeding  from  the  cut 
surface  of  the  gland  usually  is  very  slight.  By  pick- 
ing up  a  few  small  vessels  and  then  making  light 
pressure  with  a  gauze  pad  the  bleeding  ceases  within 
a  few  minutes  while  the  remaining  steps  of  the  op- 
eration are  carried  out.  The  dark  space  between  the 
retractors  (3)  and  (4)  and  the  edge  of  the  capsule 
(r)  contains  the  carotid  artery  the  internal  jugular 
vein  and  the  pneumogastric  nerve,  but  these  cannot 
be  recognized  separately  except  upon  close  inspection. 

Plate  19  represents  the  conditions  that  have  just 
been  described  in  connection  with  Plate  18  with  the 
exception  that  the  muscles  have  been  retracted  in- 
stead of  being  severed. 

In  Plate  20  the  inferior  thyroid  vein  has  been  severed 
and  the  inferior  thyroid  artery  has  been  grasped 
between  two  haemostats  (h)  and  (h")  and  is  ready 
to  be  severed.  The  distance  between  these  two 
vessels,  the  former  being  held  by  forceps  (h) 
and   (h')    is   more   nearly    as    it    is    usually    found 


PLATE  XIX 


1 

) 

A     1 

~i 

/  i^ 

»s 

3 


l4.  .<£' 


/ 


./,'_.   /v 


'<5\; 


'i/dMZ-y5_ll 


MM 


THE    SAME    AS    PLATE    XVIII,    WITH    THE    MUSCLES    KETEACTED    BUT    NOT 
SEVERED. 


PLATE  XX 


THE    SAME    AS    PLATE   XVIII,    WITH    BOTH    THE   INFERIOR    THYROID   ARTERY 
AND  VEIN   CAUGHT   IN   SEPARATE   HAEMOSTATIC  FORCEPS. 


THYROIDECTOMY  149 

than  that  shown  in  Plates  18  and  19.  In  the 
other  details  this  illustration  will  not  require 
any  further  discussion,  while  Plate  20  is  a  simple 
repetition  with  the  muscles  retracted  instead  of 
severed.  The  inferior  thyroid  artery  is  then  severed 
between  the  forceps  (h)  and  (h")  and  ligatures  are 
applied  to  all  of  the  vessels  held  by  forceps  (h)  (h")  and 
(g)  (g") .  In  this  manner  all  of  the  vessels  supplying  the 
enlarged  lobe  of  the  thyroid  gland  have  been  dis- 
posed of  with  the  least  possible  amount  of  trauma 
to  the  gland  and  with  almost  no  loss  of  blood.  The 
important  structures  behind  the  gland,  the  recurrent 
laryngeal  nerve  and  the  parathyroid  gland  have  re- 
mained entirely  undisturbed  and  the  operation  can 
be  completed  by  simply  removing  this  lobe  at  its 
junction  with  the  isthmus.  The  point  of  section 
depends  upon  whether  only  one  lobe  is  to  be  re- 
moved or  whether  a  portion  or  the  entire  isthmus 
is  to  be  removed  or  whether  it  seems  advisable  to 
add  to  this  the  removal  of  a  portion  of  the  other 
lateral  lobe. 

If  the  section  is  to  be  made  through  any  portion  of 
the  isthmus  a  pair  of  forceps  (k)  Plate  22,  is  applied 
and  the  portion  beyond  these  forceps  is  removed  by 
cutting  away  this  part  and  either  ligating  the  re- 
maining stump  with  catgut  or  suturing  over  this 
surface  with  a  few  fine  catgut  stitches.  In  exophthal- 
mic goitre  it  is  usually  well  to  lift  up  the  lower  end 
of  the  gland  by  forceps  (k)  and  then  leaving  the 
lower  end  of  the  posterior  capsule  together  with  a 
thin  layer  of  gland  tissue  on  the  other  side  and 
ligating  the  inferior  thyroid  vessels  or  some  of  their 
branches  as  this  was  done  on  the  other  side  as  illus- 


150  THYROID   GLAND 

trated  in  Plate  21.  In  this  manner  only  one  upper 
thyroid  vein  and  one  upper  thyroid  artery  possibly 
in  connection  with  one  middle  thyroid  artery  re- 
mains. 

In  making  a  dissection  of  the  isthmus  it  is  im- 
portant to  exercise  care  not  to  injure  the  trachea 
which  is  exposed  at  this  point.  In  one  instance  I  had 
the  misfortune  of  making  a  small  incision  into  the 
trachea  at  this  point  of  the  operation.  The  opening 
was  immediately  closed  with  three  fine  catgut  sutures 
and  a  small  drain  of  gauze  was  placed  against  this 
surface.  The  patient  recovered  without  any  unfavor- 
able symptoms  but  it  is  plain  that  the  blunder  should 
not  occur.  In  advanced  cases  or  in  patients  who 
have  very  hard  nodules  pressing  upon  the  trachea 
one  or  more  of  the  cartilages  may  have  become 
softened  as  a  result  of  pressure  and  when  the  isthmus 
is  removed  there  is  no  support  for  the  mucous  lining 
of  the  trachea  and  the  latter  is  drawn  into  the  lumen 
of  this  tube  by  each  act  of  inspiration  giving  rise  to  a 
valve-like  obstruction.  The  patient  will  immediately 
become  asphyxiated.  If  a  general  anaesthetic  has 
been  employed  this  may  be  blamed  for  the  condition 
of  asphyxia  until  it  is  too  late.  For  this  reason  it  is 
well  to  bear  the  possibility  of  this  accident  constantly 
in  mind.  The  difficulty  can  be  discovered  at  once 
upon  inspecting  the  surface  of  the  trachea  because 
of  the  depression  upon  inspiration. 

The  remedy  consists  in  the  introduction  of  an 
intubation  tube  sufficiently  long  to  reach  to  a  point 
below  the  softened  tracheal  cartilage.  For  this 
reason  a  set  of  intubation  tubes  and  a  reliable  gag 
should  always  be  kept  in  readiness  during  goitre 


PLATE  XXI 


y?//  fiA^\\\V\\f\\  A^kVi 


THE    SAME    AS     PLATE    XX,     WITH     THE    MUSCLES     NOT    SEVERED     BUT     RE- 
TRACTED. 


PLATE  XXII 


A, 


^jW   l 


THE  RIGHT  LOBE  OF  THE  THYROID  GLAND  ENTIRELY  DISSECTED  OUT,  BOTH 
SUPERIOR  AND  INFERIOR  THYROID  VESSELS  HAVE  BEEN  SEVERED.  THE  POS- 
TERIOR PORTION  OF  THE  CAPSULE  IS  IN  PLACE  AND  THE  ISTHMUS  IS  BEING 
COMPRESSED  WITH  LONG-JAWED  FORCEPS    (iv). 


THYROIDECTOMY  151 

operations.  If  the  obstructions  cannot  be  relieved 
by  intubation,  tracheotomy  should  be  performed. 
The  depressed  portion  of  the  tracheal  wall  should  be 
drawn  forward  and  a  longitudinal  incision  should 
be  made  and  a  tracheotomy  tube  should  be  inserted. 
If  a  tracheotomy  tube  is  not  available  it  is  usually 
not  difficult  to  improvise  some  plan  to  keep  the 
wound  in  the  trachea  open.  The  patient  should  be 
protected  against  the  inspiration  of  cold  air  by  plac- 
ing four  thicknesses  of  aseptic  gauze  over  a  frame 
five  c.  m.  or  more  above  the  wound.  If  the  air  in  the 
room  is  very  dry  it  is  well  to  drop  a  few  drops  of 
water  upon  this  screen  sufficiently  often  to  supply 
some  moisture  to  the  air  inhaled.  In  these  cases  it  is 
well  to  have  the  lower  portion  of  the  wound  widely 
open  in  order  to  avoid  serious  infection  which  might 
otherwise  give  rise  to  septic  mediastinitis. 

Plate  23  represents  the  same  stage  of  the  operation 
as  Plate  22  with  the  muscles  not  severed. 

Plates  24  and  25  represent  the  completed  operation 
with  the  exception  of  closing  the  wound.  The  entire 
right  lobe  together  with  the  entire  isthmus  has  been 
removed.  Only  the  posterior  capsule  (r)  together 
with  a  thin  layer  of  the  posterior  portion  of  the  right 
lobe  remains,  just  enough  to  protect  the  recurrent 
laryngeal  nerve  and  the  parathyroid  gland.  The 
internal  jugular  vein  and  the  common  carotid  artery 
together  with  the  superior  and  inferior  thyroid  ves- 
sels are  shown  in  a  diagramatic  manner.  The  stump 
of  the  thyroid  gland  has  been  sutured  with  a  few 
fine  catgut  sutures  as  shown  at  the  end  of  the 
forceps  (o). 


152  THYROID    GLAND 

The  left  lobe  of  the  gland  remains  in  its  normal 
condition  and  position.  The  superior  thyroid  artery 
and  vein  are  represented  as  entering  the  upper  end 
of  this  lobe,  the  muscles  having  been  held  back  by 
the  retractors  (3)  and  (3").  In  case  it  is  desired  to 
reduce  the  amount  of  blood  supply  for  the  remaining 
lobe  this  can  readily  be  accomplished  by  ligating  the 
superior  thyroid  vessels  at  this  point. 

In  Plate  25,  precisely  the  same  conditions  exist 
with  the  exception  that  the  muscles  covering  the  an- 
terior surface  of  the  thyroid  gland  have  simply  been 
drawn  out  of  the  way  by  sharp  retractors  (2)  and 
(2")  below  and  (3)  and  (3")  above.  Here  also  the  super- 
ior and  inferior  thyroid  vessels  and  the  carotid  artery 
and  deep  jugular  vein  are  represented  with  the  fascia 
entirely  removed  which  is  quite  unnecessary.  The 
capsule  (r)  which  has  been  dissected  off  the  posterior 
surface  of  the  lobe  which  has  been  removed  appears 
thicker  and  more  substantial  than  in  the  actual 
operation,  except  in  its  lower  half  where  quite  a 
layer  of  thyroid  tissue  is  left  for  the  protection  of 
the  underlying  structures. 

If  the  operation  has  been  performed  with  sufficient 
care,  the  surface  is  usually  quite  free  from  blood. 
If  any  small  surface  remains  from  which  there  is 
general  oozing,  this  can  be  controlled  by  the  intro- 
duction of  a  few  fine  catgut  stitches  tied  just  tightly 
enough  to  stop  the  oozing  but  not  with  sufficient 
force  to  cause  pressure  necrosis.  It  is,  of  course,  im- 
portant not  to  injure  the  parathyroid  glands  or  the 
recurrent  laryngeal  nerve  in  introducing  these  su- 
tures but  both  can  very  readily  be  avoided  with 
proper  care. 


PLATE  XXIII 


t  lA  I LnLJA 


THE    SAME    AS    PLATE    XXII,    WITH    THE    MUSCLES    XOT    SEVEEED    BUT    RE- 
TRACTED. 


PLATE  XXIV 


THE    RIGHT    LOBE   OF    THE    THYROID   GLAND    HAS    BEEN    REMOVED    AND    THE 
PEDICLE   SUTURED. 


THYROIDECTOMY  153 

In  order  to  prevent  absorption  of  blood  or  thyroid 
secretion  from  the  wound  surfaces  some  provision 
must  be  made  for  drainage.  It  is  best  to  drain 
through  a  separate  opening  as  shown  in  Plate  26,  in 
order  that  the  line  of  suture  may  not  be  irritated 
by  the  introduction  of  drainage  along  any  portion  of 
its  course.  The  drainage  may  be  accomplished  by  a 
simple  glass  drainage  tube  or  by  a  rubber  tube  or  by 
the  use  of  gauze  surrounded  with  rubber  tissue,  the 
cigarette  drain,  or  a  simple  gauze  drain  may  be 
employed. 

In  our  cases  a  combined  drain  composed  of  a 
layer  of  gauze  loosely  packed  into  the  wound  left 
after  the  removal  of  the  lobe  as  shown  at  (s) ,  Plate 
26,  with  the  additional  introduction  of  a  glass  drain 
have  been  most  satisfactory.  Both  the  tube  and  the 
gauze,  the  latter  surrounding  the  former,  should 
be  brought  out  at  (p),  Plate  28.  It  is  best  to  place  the 
gauze  in  such  a  manner  that  it  can  be  withdrawn 
easily  and  without  disturbing  the  tissues  after  first 
withdrawing  the  glass  tube.  The  latter  should  be 
withdrawn  on  the  second  or  third  day  after  the 
operation,  and  the  gauze  a  day  or  two  later.  It  is 
important  not  to  withdraw  the  gauze  carelessly 
because  this  may  give  rise  to  quite  troublesome 
haemorrhage  which  may  clot  underneath  the  skin 
flap  and  which  may  ultimately  cause  quite  a  delay 
in  wound  healing. 

Plate  27  represents  all  of  the  muscles  on  the  an- 
terior surface  of  the  neck  again  in  position.  It  is 
best  to  unite  these  muscles  with  a  fine  continuous 
catgut  suture. 


154  THYROID    GLAND 

Plate  28  represents  the  muscles  on  the  left  side  of 
the  patient's  neck  already  united,  those  on  the  right 
side  are  still  held  apart  in  the  grasp  of  forceps  (b)  and 
(b').  The  gauze  drain  (s)  is  in  place  and  both  this 
and  the  glass  drain  are  represented  as  issuing  through 
a  small  incision  (p)  about  two  c.  m.  below  the  trans- 
verse portion  of  the  horseshoe  incision.  Plate  29  rep- 
resents all  of  the  muscles  sutured,  the  symmetry  of 
the  neck  having  been  quite  as  thoroughly  restored 
as  in  Plate  28.  It  is  important  to  give  attention  to 
these  steps  represented  in  Plates  27,  28  and  29,  be- 
cause this  will  prevent  the  very  troublesome  de- 
formities which  one  is  sure  to  encounter  if  this  pre- 
caution is  not  taken. 

The  only  step  remaining  in  order  to  complete  the 
operation  is  the  closure  of  the  principle  incision  as 
shown  in  Plate  30.  If  only  the  skin  suture  is  employed 
there  is  usually  a  considerable  amount  of  spreading 
of  the  scar  because  of  the  traction  on  part  of  the 
platysma  myoides  muscle.  On  the  other  hand  if 
the  wound  is  closed  by  the  sub-cuticular  suture 
alone,  a  rather  unsightly  thickening  is  likely  to 
occur  at  the  line  of  suture.  In  order  to  avoid  both 
of  these  sources  of  annoyance  it  is  advisable  to  place 
about  six  interrupted  sub-cuticular  sutures  of  fine 
catgut  along  the  line  of  incision  at  regular  intervals 
uniting  the  platysma  myoides  and  the  sub-cutaneous 
connective  tissue.  This  will  remove  all  tension  from 
the  skin  proper  and  will  leave  an  almost  invisible 
line  of  suture  provided  silk  or  horsehair  is  used  and 
the  edges  are  carefully  and  evenly  united  and  the 
sutures  drawn  just  sufficiently  tight  to  secure  accurate 
coaption  but   not   to   cause   any  pressure  necrosis. 


PLATE  XXV 


THE     SAME    AS    PLATE    XXIV,    WITH     THE     MUSCLES    RETRACTED    BUT    NOT 
SEVERED. 


THYROIDECTOMY  155 

These  sutures  can  be  cut  on  the  fourth  or  fifth  day 
which  will  prevent  the  occurrence  of  even  the  slightest 
suture  marks. 

The  operation  which  has  just  been  described  may 
be  employed  with  equal  satisfaction  in  the  removal 
of  portions  of  the  thyroid  gland  for  whatever  con- 
dition may  demand  this  procedure.  The  operation 
is,  of  course,  more  serious  in  proportion  with  the 
severity  of  the  pathological  condition  present  in  the 
patient  under  consideration.  Generally  speaking, 
in  patients  suffering  from  exophthalmic  goitre  this 
condition  makes  the  operation  more  serious  than  in 
simple  goitre  and  it  may  be  well  at  this  point  to 
insist  upon  the  fact  that  although  all  of  the  steps 
of  the  operation  are  relatively  simple,  still  the  opera- 
tion itself  must  be  looked  upon  as  one  of  the  serious 
major  surgical  procedures  which  should  not  be  un- 
dertaken by  inexperienced  surgeons,  because  in- 
many,  possibly  in  most  of  these  patients,  there  is 
but  a  relatively  narrow  margin  even  with  much  ex- 
perience and  excellent  skill  and  splendid  surgical 
judgment.  It  seems  proper  to  direct  attention  to  this 
fact  at  this  point  because  the  low  mortality  of  men 
with  great  skill  and  remarkable  judgment  might 
otherwise  cause  those  not  so  well  equipped  to  suffer 
severe  disappointment  and  the  loss  of  many  patients. 

Ligation  of  Thyroid  Vessels.  Kocher  has  point- 
ed out  the  fact  that  in  many  cases  the  patient 
is  too  weak  to  bear  the  radical  operation  of  thy- 
roidectomy in  cases  of  exophthalmic  goitre.  In  all 
of  these  cases  an  attempt  must  be  made  to  build  up 
the  patient's  strength  by  rest,  diet  and  the  use  of 
appropriate    remedies,    but    there    are    some    cases 


156  THYROID    GLAND 

which  seem  to  become  worse  constantly,  notwith- 
standing this  treatment.  In  some  instances  the 
patient's  condition  may  be  so  bad  that  even  the 
slightest  operation  would  result  fatally,  but  there  is 
another  class  which  will  bear  a  very  slight  operation 
but  cannot  bear  the  shock  of  thyroidectomy.  In 
this  class  of  cases  Kocher  recommends  the  ligation 
of  one  or  more  vessels  as  a  preliminary  operation. 
This  will  reduce  the  production  and  absorption  of 
thyroid  poison  to  a  sufficient  extent  that  the  patient's 
general  condition  may  improve  sufficiently  to  make 
it  safe  to  perform  a  more  serious  operation  after  a 
few  weeks  of  recuperation. 

Not  enough  experience  has  been  accumulated 
to  determine  positively  whether  this  plan  should  be 
generally  adopted.  Kocher  seems  confident  that  it 
is  indicated  in  certain  cases  and  his  enormous  ex- 
perience and  wonderful  surgical  judgment  must 
always  carry  more  weight  in  this  subject  than  that 
of  any  other  surgeon  with  the  single  exception 
of  Charles  H.  Mayo,  consequently  we  must,  for  the 
present,  accept  this  view,  although  its  correctness 
has  been  questioned  by  many  surgeons,  no  less  an 
authority  than  Landstrom  among  them.  These  sur- 
geons have  pointed  out  the  fact  that  the  mortality 
after  simple  ligation  has  been  greater  than  after  ex- 
cision of  one  lobe,  but  as  the  former  operation  is  em- 
ployed only  in  cases  that  are  in  an  almost  hopeless  con- 
dition while  the  latter  operation  is  practiced  in  the  less 
serious  cases  no  comparison  can,  of  course,  be  made- 
because  the  two  operations  are  performed  on  patients 
whose  prognosis  would  be  entirely  different  were 
they  operated  for  any  other  condition.    Those  upon 


PLATE  XXVI 


>vr 


SHOWS  THE  OPERATION  COMPLETED  TO  THE  POINT  OF  CLOSING  THE 
WOUND.  (S)  GAUZE  TAMPON;  (p)  SEPARATE  OPENING  FOR  GLASS  DRAIN  AND 
GAUZE. 


THYROIDECTOMY  157 

whom  the  former  operation  is  practiced  would  have 
but  a  very  slight  chance  of  recovery  after  almost  any 
operation,  while  those  subjected  to  the  latter  opera- 
tion would  be  almost  certain  to  recover  from  any 
operation  which  would  not  in  itself  be  dangerous. 

Having  accepted  the  theory  that  ligation  in  itself 
is  a  less  severe  procedure  than  removal  of  one  lobe, 
we  must  choose  between  the  various  operations 
which  have  been  recommended,  namely:  The  liga- 
tion of  as  many  arteries  and  veins  as  it  seems  safe 
to  ligate  in  any  given  case  as  recommended  by 
Kocher;  the  ligation  of  as  many  veins  as  seems  safe, 
as  recommended  by  Tuholske;  and  the  ligation  of 
both  upper  poles  of  the  thyroid  gland  including 
arteries,  veins,  and  lymph  channels  by  passing 
double  ligatures  around  the  entire  upper  pole  on 
both  sides,  including  the  gland  together  with  both 
superior  arteries  and  veins  and  the  capsule  as  recom- 
mended by  Werelins  and  Jacobson. 

Of  these  methods  the  one  recommended  by  Kocher 
has  been  employed  most  frequently.  If  it  seems  as 
though  the  ligation  of  the  superior  thyroid  vessels' 
on  one  side  is  as  much  as  the  patient  can  safely  en- 
dure at  the  first  sitting,  then  the  skin  is  cocainized 
along  the  anterior  border  of  the  sterno-cleido -mastoid 
muscle  from  the  point  (a)  or  (b),  Plates  2  and  30, 
downward  for  a  distance  of  five  c.  m.  A  puncture  is 
then  made  with  a  fine  sharp  scalpel  through  the  skin 
at  the  point  (a)  or  (b)  according  to  the  side  on  which 
there  is  the  greatest  amount  of  enlargement,  then  a 
blunt-pointed  hypodermic  needle  with  a  lateral 
opening  attached  to  a  syringe  containing  the  anaes- 
thetizing  solution  is  passed  into  the  deep  tissues 


158  THYROID    GLAND 

along  the  anterior  border  of  the  sterno-mastoid 
muscle  and  a  sufficient  amount  of  fluid  is  injected  to 
thoroughly  anaesthetize  the  tissue  to  be  manipulated 
later.  After  waiting  for  five  minutes  the  skin  is  in- 
cised, the  muscles  covering  the  anterior  surface  of 
the  lobe  are  retracted  outward  and  the  superior 
•thyroid  artery  and  vein  are  exposed,  isolated  and 
elevated  with  a  Kocher  director  either  singly  as 
shown  in  Plate  22,  or  together.  They  are  then  caught 
with  two  pair  of  haemostatic  forceps  and  ligated  as 
shown  at  (e)  and  (e')  and  (e")  and  (e"'),  Plate  13. 
It  is  not  necessary  to  expose  the  entire  gland  as  shown 
in  these  figures  to  accomplish  this  which  can  easily 
be  4one  through  the  incision  described  above.  If 
the  patient  is  in  a  satisfactory  condition  after  this 
has  been  done  on  one  side  the  same  thing  may  be 
done  on  the  opposite  side  immediately.  This  is 
usually  the  better  plan  because  as  has  been  shown 
all  of  the  arteries  and  veins  of  the  thyroid  gland  are 
so  thoroughly  anastomosed  that  the  ligation  of  only 
one  of  the  four  principle  arteries  and  veins  has  but 
little  influence  upon  the  production  and  absorption 
of  thyroid  toxins  while  the  ligation  of  both  superior 
thyroid  arteries  and  veins  seems  '  to  have  a  very 
marked  effect.  Were  it  possible  at  the  same  time 
to  ligate  also  the  inferior  thyroid  artery  and  vein  on 
one  side  the  results  would  be  still  better,  but  the 
amount  of  trauma  inflicted  by  the  ligation  of  one  in- 
ferior artery  and  vein  is  much  greater  than  that  re- 
quired in  the  ligation  of  both  sides  above,  hence, 
most  patients  who  are  sufficiently  strong  to  bear 
the  ligation  of  three  sets  of  vessels  are  quite  strong 


PLATE  XXVII 


ft 


CHiCflOQ 


THE   MUSCLE  IN    FRONT   OF  THE    THYROID   GLAND    HAS   BEEN    SUTURED. 


PLATE  XXVIII 


THE   SAME   AS   PLATE   XXVI,   WITH   THE   ADDITION    OF    SUTURING   THE   MUS- 
CLES  WHICH   HAD  BEEN    SEVERED   TRANSVERSELY. 


THYROIDECTOMY  159 

enough  to  bear  the  excision  of  one  thyroid  lobe  at 
the  same  time. 

In  case  there  is  a  sufficient  amount  of  enlarge- 
ment present  to  make  it  desirable  to  excise  one 
lobe  later,  it  is  probably  better  to  make  the  incision 
shown  in  Plates  22  and  30,  and  to  turn  up  the  flap  as 
shown  in 'Plate  31,  because  the  incision  can  be  made 
in  a  few  moments  entirely  painless  under  local 
anaesthesia.  The  ligation  of  the  anterior  jugular  vein 
as  shown  in  Plates  31  and  32,  will  dispose  of  a  greatly 
enlarged  vessel.  The  muscles  anterior  to  the  thyroid 
gland  can  be  separated  easily  and  the  ligation  of 
the  superior  thyroid  vessels  can  be  secured  in  a 
shorter  time  than  through  two  separate  incisions. 
At  the  same  time  a  double  suture  may  be  passed 
around  a  number  of  the  superficial  branches  of  the 
inferior  thyroid  vessels  on  the  side  on  which  the  gland 
is  enlarged.  The  flap  can  be  brought  down  into  place 
after  all  this  has  been  accomplished  and  held  in 
proper  position  by  the  insertion  of  from  four  to 
eight  fine  catgut  sutures  which  grasp  the  platysma 
and  the  sub-cutaneous  connective  tissue. 

This  operation  requires  somewhat  less  skill  than 
the  one  first  described.  In  case  the  gland  is  not 
sufficiently  enlarged  on  either  side,  however,  to  in- 
dicate its  removal  it  is  not  necessary  to  make  this 
long  incision.  On  the  other  hand  if  it  is  desirable  to 
remove  an  enlarged  lobe,  the  patient  will  usually 
be  in  condition  to  have  this  secondary  operation 
made  in  from  one  to  two  weeks,  when  the  flap  can 
be  turned  up  again  and  the  operation  for  excision 
of  the  thyroid  gland  which  has  already  been  fully 
described,  may  be  performed. 


160  THYROID*  GLAND 

Ligation  of  Thyroid  Veins.  It  has  been  sug- 
gested by  Tuholske  that  the  ligation  of  the  thyroid 
veins  would  reduce  the  introduction  of  thyroid 
poison  into  the  general  circulation  to  such  an  extent 
that  the  hyperthyroidism  of  exophthalmic  goitre 
would  be  abolished  while  there  would  be  no  danger 
of  myxoedema  because  the  gland  itself  would  not 
be  removed.  This  theory  seems  to  be  borne  out  by 
the  clinical  observations  as  set  forth  in  this  most 
interesting  article  and  it  is  possible  that  the  opera- 
tion suggested  will  receive  a  recognized  position 
after  it  has  been  tested  for  a  sufficient  period  of  time. 
At  this  time  it  seems  of  sufficient  importance  to  de- 
mand our  consideration. 

Operation.  An  incision  is  made  as  indicated  in 
Plates  2  and  30,  the  flap  of  skin  and  platysma  is  re- 
flected as  shown  in  Plate  32,  and  the  sternohyoid, 
sternothyroid  and  omohyoid  muscles  are  retracted  as 
shown  in  Plates  31  and  32.  The  anterior  jugular  vein 
and  its  branches  areligated,  then  the  two  superior  thy- 
roid veins  are  isolated,  the  Kocher  director  is.  in- 
serted underneath  each  vein  and  two  haemostatic 
forceps  are  applied  as  shown  in  (e)  and  (e'),  Plate  14, 
the  veins  are  severed  and  ligated  as  shown  in  Plates 
31  and  32.  It  is  a  relatively  easy  matter  to  ligate  the 
superior  thyroid  veins  because  they  are  quite  super- 
ficial and  easily-isolated.  The  inferior  thyroid  veins 
on  the  other  hand  cannot  be  isolated  so  easily  be- 
cause they  enter  the  gland  from  behind  and  it  is 
consequently  necessary  to  lift  the  lower  border  of 
the  gland  forward  in  order  to  expose  these  veins. 
In  discussing  the  excision  of  the  lateral 'lobe  of  the 
thyroid  gland  it  was  shown  that  by  first  ligating  the 


PLATE  XXIX 


CHICAGO 


THE   SAME  AS   PLATE   XXVII,  WITH   THE  ADDITION   OF    SUTURING   ALL   MUS- 
CLES  WHICH    HAD  BEEN   SEVERED  TRANSVERSELY. 


PLATE  XXX 


SHOWS    THE    EXTERNAL    WOUND    COMPLETELY     CLOSED,     WITH     DRAINAGE 
TUBE  AND  GAUZE  ISSUING  FROM   THE  SEPARATE  INCISION  BELOW  AT    (p). 


THYROIDECTOMY  161 

superior  thyroid  vessels  and  dislocating  the  lobe  for- 
ward it  is  not  very  difficult  to  ligate  the  inferior 
thyroid  vessels,  although  there  is  great  danger  of  in- 
juring the  recurrent  laryngeal  nerve  and  the  para- 
thyroid gland  on  the  side  involved. 

It  is  much  more  difficult  to  isolate  the  inferior 
thyroid  vein  when  the  superior  thyroid  artery  has 
not  been  severed  and  this  difficulty  increases  with 
the  size  of  the  lobe,  but  as  this  operation  is  indicated 
only  in  cases  in  which  the  excision  of  the  lobe  need  not 
be  considered  because  of  its  enlargement  one  will, 
of  course,  not  be  called  upon  to  ligate  the  inferior 
thyroid  veins  in  any  case  in  which  there  is  a  consider- 
able enlargement  of  either  lobe,  but  only  in  cases 
in  which  the  symptoms  of  exophthalmic  goitre  exist 
without  much  enlargement  of  the  thyroid  gland. 

In  this  class  of  cases  it  is  possible  to  draw  forward 
the  lower  border  of  the  gland  sufficiently  to  isolate 
the  inferior  thyroid  vein  as  shown  in  Plates  31  and  32, 
and  to  elevate  it  as  shown  at  (n)  with  a  Kocher 
director.  Then  two  forceps  are  applied  as  shown  at 
(m)  and  (m/),  the  vessel  is  cut  and  ligated  as  shown  at 
(m")  and  (m" ') .  The  vein  is  located  to  the  inner 
side  of  the  artery  and  is  not  in  as  close  relation  to  the 
recurrent  laryngeal  nerve  as  the  latter,  hence,  the 
operation  is  easier  and  safer  than  the  ligation  of  the 
inferior  thyroid  artery.  In  ligating  the  inferior 
thyroid  artery  it  is  always  necessary  to  expose  the 
recurrent  laryngeal  nerve  because  it  is  only  by  doing 
this  that  one  can  be  certain  that  the  latter  is  not  in- 
jured during  some  part  of  the  manipulation.  In 
ligating  the  inferior  thyroid  vein,  on  the  other  hand, 
it  is  necessary  only  to  expose  the  structure  carefully 


162  THYROID    GLAND 

on  the  Kocher  director  as  shown  in  Plates  31  and  32, 
in  order  to  avoid  injuring  either  the  recurrent  laryn- 
geal nerve  or  the  parathyroid  gland.  In  ligating  the 
inferior  thyroid  artery  it  is  also  important  to  ligate 
near  the  entrance  of  this  vessel  into  the  gland  in 
order  not  to  ligate  the  branch  which  sometimes  sup- 
plies the  parathyroid  gland.  It  is  not  necessary  to 
take  a  corresponding  precaution  in  ligating  the  in- 
ferior thyroid   vein. 

What  has  just  been  said  would  indicate  that  this 
operation  requires  much  surgical  skill  and  anatomic 
familiarity  aside  from  that  absolutely  required  in 
performing  thyroidectomy,  but  if  the  results  will 
justify  the  operation  it  will  not  be  difficult  to  acquire 
these. 

The  closure  of  the  wound  should  be  the  same  as 
described  in  connection  with  Plate  30.  It  is  not 
necessary,  however,  to  make  so  extensive  a  flap 
in  order  to  perform  this  operation."  The  superior 
thyroid  veins  can  be  ligated  through  two  incisions 
parallel  with  the  anterior  border  of  the  sterno- 
cleido-mastoid  muscle  five  c.  m.  long,  extending 
downwards  from  (a)  and  (b),  Plates  2  and  20,  and 
the  inferior  thyroid  and  the  anterior  jugular  veins 
can  be  ligated  through  a  transverse  incision  five  cm. 
long  occupying  the  portion  of  the  incision  represented 
in  Plates  2  and  20,  passing  across  the  middle  of  the 
neck.  The  deformity  following  the  closure  of  these 
three  incisions  or  the  horseshoe  incision  is  very 
slight  in  these  cases  if  the  platysma  and  sub-cutan- 
eous connective  tissue  are  sutured  separately  as 
described  in  connection  with  the  previous  operation. 


PLATE  XXXI 


SHOWS  THE  ENTIRE  ANTERIOR  SURFACE  OF  THE  THYROID  GLAND  EXPOSED, 
WITH  THE  SUPERIOR  THYROID  VEINS  CUT  AND  LIGATED  AND  THE  INFERIOR 
ONES  CAUGHT  IN  HAEMOSTATIC  FORCEPS  AND  CUT  ON  THE  LEFT  SIDE  AND 
ISOLATED   WITH  KOCHER  DIRECTOR   ON  THE  RIGHT  SIDE. 


PLATE  XXXII 


THE    SAME    AS    PLATE    XXXI,    WITH    THE    MUSCLES    NOT    CUT    BUT    SIMPLY 
RETRACTED. 


CHAPTER  IX. 


OTHER   OPERATIONS   ON   THE 
THYROID   GLAND. 


Ligation  of  the  Superior  Poles.  Ligation  of 
both  superior  poles  of  the  thyroid  gland  has  been 
developed  and  practiced  by  J.  H.  Jacobson  of  To- 
ledo, Ohio,  at  the  suggestion  of  M.  Stamm,  of  Fre- 
mont, Ohio,  for  the  cure  of  exophthalmic  goitre. 
So  far  eight  cases  have  been  operated  by  this  method. 
The  underlying  theory  for  this  operation  is  based 
upon  the  fact  that  by  ligating  both  upper  poles  of 
the  thyroid  gland  in  patients  suffering  from  exoph- 
thalmic goitre,  the  gland  is  not  only  deprived  of  its 
most  important  blood  supply,  but  the  lymph  channels 
through  which  the  greatest  portion  of  the  thyroid 
secretion  is  supposed  to  reach  the  general  circulation 
are  included  in  the  ligature  and  permanently  in- 
terrupted. The  results  in  all  of  the  cases,  with  one 
exception,  in  which  the  operation  was  performed  in 
a  patient  who  was  moribund  at  the  time  of  operation 
have  been  most  satisfactory.  Of  course,  the  number 
of  patients  is  not  sufficiently  large,  and  the  time  ex- 
pired since  the  operation  is  as  yet  too  short  to  make 
a  final  judgment  as  to  its  value  possible,  but  there 
seems  to  be  enough  in  its  favor  to  demand  our  care- 
ful consideration. 

Stamm- Jacobson  Operation.  One  upper  pole  of 
the  gland  is  located  by  palpation  and  exposed  by  an 


164  THYROID    GlvAND 

incision  from  two  to  four  c.  m.  in  length  through 
the  skin,  superficial  fascia,  and  platysma  exposing 
first  the  anterior  border  of  the  sterho-cleido-mastoid 
muscle  directly  overlying  the  pole.  The  authors 
make  a  transverse  incision  but  as  this  leaves  a  more 
unsightly  scar  on  the  neck  than  an  incision  parallel 
with  the  anterior  border  of  the  sterno-mastoid  muscle, 
the  latter  incision  would  be  preferable  in  this  as  well 
as  in  the  two  operations  just  described. 

The  inner  border  of  the  sterno-mastoid  is  then 
loosened,  raised  and  retracted  exposing  the  fibres 
of  the  sternothyroid  muscle  which  extend  in  the 
opposite  direction.  These  fibres  are  retracted  for 
about  one  inch  exposing  the  deep  fascia  covering 
the  thyroid  gland.  This  fascia  is  next  divided  and 
the  capsule  of  the  gland  brought  into  view.  The 
muscles  are  well  retracted  by  blunt  hooks.  A  strong 
double  ligature  is  then  passed  around  the  pole  of 
the  gland  outside  of  the  capsule  by  means  of  a 
ligature  carrier,  or  a  large  pedicle  or  aneurism  needle. 
The  authors  advise  the  use  of  heavy  silk  or  linen 
ligatures  because  of  the  slowness  with  which  these 
are  absorbed.  The  two  ligatures  are  separated  one 
to  one  and  one-half  c.  m.  from  each  other  and  tied 
very  firmly.  Immediately  after  the  ligation  the 
tissues  between  and  in  the  vicinity  of  these  ligatures 
becomes  very  severely  blanched  and  undoubtedly 
the  tissue  between  the  two  ligatures  will  become 
absorbed,  permanently  disposing  of  the  arteries, 
veins  and  lymph  channels  in  both  upper  poles  of  the 
thyroid  gland. 

Plate  33  represents  the  appearance  of  each  pole 
with  the  double  ligature  in  place.   In  the  actual  oper- 


PLATE  XXXIII 


SHOWS    THE   LIGATION   Of    BOTH    SUPERIOR    POLES    OF  THYROID   GLAND. 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  165 

ation  the  structures  would,  of  course,  not  be  exposed 
as  thoroughly,  as  the  operation  is  performed 
through  a  small  incision,  '  the  extensive  exposure 
shown  in  this  figure  not  being  necessary.  If  one 
does  not  injure  the  deep  jugular  vein  or  the  carotid 
artery  externally  no  harm  is  likely  to  be  done  by 
the  passage  of  the  ligature.  In  some  instances  it 
is  difficult  to  pass  the  ligature  because  of  the  ad- 
hesions between  the  upper  pole  of  the  gland  and 
the  surrounding  structures,  especially  on  the  outer 
side,  but  by  a  slight  amount  of  blunt  dissection  this 
difficulty  can  readily  be  overcome. 

This  operation  promises  much  but  only  careful 
observation  of  a  large  number  of  cases  can  deter- 
mine its  actual  value. 

Enucleation  of  Thyroid  Tumors.  Occasionally 
the  surgeon  encounters  a  circumscribed  tumor  in 
one  of  the  lobes  of  the  thyroid  gland  which  may 
suggest  its  removal  without  excising  the  lobe  in 
which  this  is  found. 

.Usually  the  lobe  contains  a  number  of  these  en- 
larged lobules  or  cysts,  and  one  can  confidently  ex- 
pect that  the  removal  of  the  large  cyst  will  be  fol- 
lowed by  the  development  of  others. 

It  is  consequently  wise  to  make  an  enucleation 
only  in  cases  in  which  there  is  actually  a  solitary 
cyst  or  a  solitary  fibroma.  The  operation  is  usually 
safe  and  simple  and  readily  carried  out. 

Operation.  An  incision  is  made  over  the  most 
prominent  portion  of  the  gland  directly  over  the 
cyst  parallel  with  the  natural  lines  of  the  neck.  The 
muscles  are  separated  and  held  apart  with  retractors. 
The  vessels  on  the  surface  of  the  gland  are  caught 


166  THYROID    GLAND 

with  two  pairs  of  forceps,  cut  and  ligated  doubly. 
Then  the  incision  is  carried  down  to  the  cyst  through 
the  substance  of  the  gland.  The  cyst  wall  can  be 
recognized  by  the  abundance  of  connective  tissue 
fibres  it  contains. 

It  is  then  enucleated  either  with  the  finger  or  by 
means  of  a  blunt  dissector.  The  cavity  is  tamponed 
with  a  hot  gauze  pad.  If  there  are  any  vessels  that 
continue  to  bleed  these  are  caught  with  haemostatic 
forceps  and  ligated  or  a  few  fine  catgut  sutures  are 
applied.  Occasionally,  though  rarely,  the  haemorr- 
hage is  so  severe  that  the  superior  or  inferior  thy- 
roid vessels  have  to  be  ligated  and  sometimes  thy- 
roidectomy must  be  made. 

The  cavity  is  then  tamponed  with  gauze  and  a 
glass  drain  is  inserted  and  the  wound  is  closed.  In 
this  and  in  the  previous  operations  the  glass  drain 
introduced  by  Kocher  is  most  satisfactory. 

Malignant  Growths  of  the  Thyroid  Gland.  Car- 
cinoma of  the  thyroid  is  far  more  common  than 
sarcoma,  but  as  both  conditions  are  hopeless  so  far 
as  treatment  is  concerned,  when  advanced  far  enough 
to  be  diagnosed,  it  might  be  proper  to  consider 
these  conditions  together. 

In  a  number  of  cases  in  which  a  thyroidectomy 
has  been  performed  for  the  relief  of  simple  goitre 
in  which  a  postoperative  microscopic  examination 
has  demonstrated  the  presence  of  carcinoma,  the 
patient  has  remained  free  from  recurrence  because 
of  the  fact  that  the  growth  had  not  as  yet  ad- 
vanced beyond  the  limits  of  the  gland  at  the  time 
it  was  removed. 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND   167 

In  a  structure  with  such  complete  anastomosis  of 
arteries  and  veins  and  as  vascular  as  this  structure 
no  other  outcome  could  be  expected.  Unless  some 
reliable  plan  for  making  a  diagnosis  is  introduced 
which  will  demonstrate  the  presence  of  malignancy 
in  the  enlarged  gland  before  it  can  be  recognized  by 
the  unaided  senses,  we  are  not  likely  to  be  able  to 
make  a  favorable  prognosis  in  cases  of  carcinoma  or 
sarcoma  of  the  thyroid  gland.  At  present  it  seems 
possible  that  some  cytolitic  method  may  be  devel- 
oped which  will  make  it  possible  to  recognize  the 
presence  of  carcinoma  during  its  earliest  stages,  but 
as  yet  this  has  not  been  perfected. 

In  carcinoma  the  gland  is  enlarged,  somewhat 
nodulated,  usually  very  sessile  and  there  is  a  distinct 
•tendency  toward  infiltration  of  surrounding  tissues. 
Fig.  20  represents  a  patient  suffering  from  carcinoma 
of  the  right  breast  and  carcinoma  of  the  thyroid 
gland.  The  picture  shows  how  the  nipple  is  retracted, 
and  in  the  neck  one  can  see  how  the  skin  is  becoming 
involved  by  the  invasion  from  below  causing  the 
latter  to  become  adherent,  indurated  and  retracted 
in  places. 

Later  on  there  is  usually  marked  obstruction  to 
the  venous  circulation  so  that  the  veins  stand  out 
to  a  marked  extent  in  the  vicinity  of  the  gland  as 
shown  in  Figs.  21  and  22. 

This  condition  can  occasionally  be  mistaken  for  a 
sub-acute  inflammation  of  the  gland  which  is  called 
strumitis  when  it  occurs  in  a  gland  which  had  pre- 
viously been  enlarged,  or  thyroiditis  if  it  occurs  in 
a  gland  previously  normal.  In  rare  cases  this  con- 
dition  may  be   due   to   tuberculosis   of  the  gland. 


168 


THYROID    GLAND 


This  can  be  determined  by  the  use  of  the  tuberculin 
test.  In  four  cases  I  have  encountered  an  infection 
in  a  carcinomatous  thyroid  gland,  consequently  it 
is  not  safe  to  give  a  favorable  prognosis  because  of 
the  undoubted  presence  of  an  infection,  because  the 
proximity  of  the  trachea  and  larynx  makes  an  in- 
fection very  possible  in  carcinoma.  This  complica- 
tion is  very  likely  to  cause  an  obstruction  of  the 


Fig.  20.     Carcinoma  of  thyroid  gland  and  of  right  breast. 

larynx  threatening  the  patient's  life  by  suffocation. 
In  this  complication  intubation  or  tracheotomy  may 
be  indicated  but  it  is  usually  best  simply  to  give  a 
sufficient  amount  of  anodynes  to  relieve  the  patient's 
suffering. 

The  growth  may  increase  rapidly  in  size  or  it  may 
remain  almost  stationary  for  weeks  or  months,  or  in 
rare  instances  even  for  years.  When  operated  upon, 
however,  there  seems  to  be  a  rapid  increase  in  size. 
It  seems  wise  to  remove  the  entire  lobe  and  the  isth- 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  169 

mus  of  every  goitre  in  patients  forty  years  of  age  or 
older  in  whom  one  suspects  the  possibility  of  the 
occurrence  of  malignancy,  because  in  this  way  it  will 
undoubtedly  be  possible  to  remove  a  number  of 
incipient  carcinomata  permanently.  The  operation 
is  safe  and  the  patient  will  be  relieved  of  pressure 
and  of  a  repulsive  deformity,  and  may  be  saved  the 
development  of  an  incurable  carcinoma. 

It  is  not  always  possible  to  make  a  differential 
diagnosis  between  carcinoma  and  sarcoma  of  the 
thyroid  gland  but  what  has  been  said  concerning  the 
hopelessness  of  the  former  may  properly  be  repeated 
concerning  the  latter.  In  my  experience  sarcoma 
has  grown  more  rapidly  than  carcinoma.  The  skin 
has  remained  free  from  the  underlying  tumor  and 
the  surface  of  the  growth  has  presented  lobes  rather 
than  nodules.  Figs.  23  and  24  represent  a  typical 
advanced  case. 

In  one  case  of  rapidly  advancing  carcinoma  of  the 
thyroid  gland  in  a  woman  fifty-eight  years  of  age, 
who  came  under  my  care  two  years  ago,  the  patient's 
condition  was  so  severe  from  pressure  upon  the 
trachea  that  she  was  placed  in  the  hospital  where 
an  intubation  or  a  tracheotomy  could  be  made  at 
any  moment.  In  the  meantime  twenty-minute  ex- 
posures were  made  with  the  x-ray  daily  with  a 
moderately  hard  tube  at  a  distance  of  twelve  inches. 
Within  a  week  the  patient  could  breathe  without 
gasping,  in  a  month  she  could  lie  down  and  there 
was  a  slight  reduction  in  the  size  of  the  growth  and 
then  it  became  stationary,  and  somewhat  softer.  It  has 
remained  in  this  condition  for  eighteen  months  with- 
out treatment.     None  of  the  other  cases  have  re- 


170  .  THYROID    GLAND 

sponded  in  this  manner.  In  sarcoma  it  may  be  ad- 
visable to  employ  the  x-ray  and  possibly  also  Coley's 
serum,  but  all  advanced  cases  must  be  looked  upon 
as  practically  hopeless. 

Transplantation  of  the  Thyroid  Gland.  Experi- 
mentally it  has  been  shown  that  the  thyroid 
gland  can  be  transplanted  from  its  normal  position 


Fig.  21.     Anterior  view  of  carcinoma  of  thyroid  gland  showing 
greatly  enlarged  veins. 

to  other  portions  of  the  body  of  the  same  animal,  or 
it  may  be  transplanted  from  one  animal  to  another 
of  the  same  species.  Many  locations  were  chosen  by 
various  authors.  Kocher  transplanted  a  thyroid 
gland  under  the  skin  of  the  neck ;  Von  Eiselberg  into 
the  peritoneal  space ;  Payr  into  the  spleen ;  Serman 
made  a  cavity  in  the  tibia  and  transplanted  the  gland 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  171 

into  this  space.  Schiff  demonstrated  in  the  year  1884 
that  it  is  possible  to  keep  animals  alive  whose  thy- 
roid glands  had  been  removed  by  transplanting  the 
thyroid  gland  of  the  same  species  of  animal  into 
some  portion  of  this  animal,  while  other  similar 
animals  invariably  died  of  myxcedema  after  com- 
plete thyroidectomy  without  transplantation.  The 
histological  examination  of  the  transplanted  gland 
has  shown  that  a  portion  of  the  tissue  is  invariably 
absorbed.  It  has  been  found  that  rapid  transplanta- 
tion and  aseptic  healing  decreases  the  amount  of 
degeneration  and  that  it  is  important  not  to  injure 
the  tissues  of  the  gland  by  violent  manipulations. 
Experiments  have  been  made  by  injecting  crushed 
thyroid  substance  sub-cutaneously  or  interstitially 
with  the  idea  of  supplying  thyroid  tissue  to  the 
patient  without  the  necessity  of  subjecting  her  to  an 
operation  which  in  itself  would  subject  the  patient 
to  a  considerable  strain. 

Should  we  attempt  to  discuss  the  subject  of  trans- 
plantation of  the  thyroid  gland  in  all  of  its  phases 
too  much  space  would  have  to  be  consumed  and  there 
would  not  be  much  practical  advantage  gained  by 
this  as  these  experimentations  and  clinical  studies 
have  not  as  yet  reached  a  point  where  it  would  be 
proper  to  draw  positive  conclusions  upon  which  one 
could  reasonably  base  therapeutic  practice.  Salzer 
has  recently  reviewed  this  subject  most  carefully 
and  has  made  a  large  number  of  most  interesting 
animal  experiments  based  chiefly  upon  the  observa- 
tions and  experiments  of  von  Eise]berg,  Enderlen, 
Christens,  Payr,  Sultan  and  others,  and  it  has  seemed 
to  me  that  for  the  present  it  will  be  wise  to  accept 


172 


THYROID    GLAND 


his  view  of  this  subject  because  he  has  reviewed  the 
subject  in  a  most  logical  manner  and  supports  his 
views  by  definite  postmortem  findings  in  a  sufficient 
number  of  animal  experiments  to  make  his  theories 
plausible. 

Salzer  finds  that  in  transplanting  the  thyroid  gland 
into   animals  that  have  been  completely  deprived 


|.     ■  i              _± 

1 

| 

V        b  f    ■ 

! 

L       iLiJ 

1 

^- I 

\        — 

H^i 

i 

i          m 

\ 

.  > 

Fig.  22.     Shows  a  lateral  view  of  the  same  case.      (Fig.  21.) 

of  this  structure,  the  transplanted  gland  becomes  an 
active  part  of  its  new  host  or  of  its  old  host  in  any 
location  more  quickly  than  it  does  if  the  animal  has 
been  deprived  of  only  a  portion  of  its  thyroid  gland 
or  if  its  thyroid  gland  has  not  been  disturbed.  More- 
over, the  amount  of  degenerative  changes  under  the 
former  condition  is  much  less  than  under  the  latter. 
In  other  words,  the  tissues  of  the  animal  seem  to 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  173 

require  the  active  thyroid  gland  as  a  part  of  the 
organism  and  when  this  has  been  removed  from  its 
normal  location  there  seems  to  be  an  inherent 
tendency  to  provide  for  its  participation  in  the 
physiological  activity  of  the  tissues  of  the  body  at 
the  earliest  possible  moment.  He  also  finds  that 
under  this  condition  the  gland  which  has  been  trans- 
planted to  the  abdominal  wall  actually  takes  up  its 
physiological  function,  that  the  production  of  colloid 
substance  is  sufficient  and  that  the  vascularization 
of  the  gland  equals  that  in  its  normal  location.  He 
favors  the  abdominal  wall  for  the  location  because 
his  experiments  have  demonstrated  this  to  be  satis- 
factory and  because  it  is  a  simple  surgical  procedure 
which  is  perfectly  safe  and  can,  of  course,  be  re- 
peated in  case  it  becomes  apparent  that  the  amount, 
of  thyroid  tissue  transplanted  at  first  is  not  suffi- 
cient to  supply  the  physiological  needs  of  the  patient 
which  would  become  apparent  by  the  recurrence  of 
symptoms  of  myxoedema. 

It  seems  likely  that  this  method  will  be  applicable 
in  cases  of  myxoedema  and  especially  in  cretinism. 
The  method  employed  in  animal  experimentation 
could  be  applied  to  these  cases. 

Technic  of  Transplantation  of  Thyroid  Gland. 
The  patient  into  whose  body  the  gland  is  to  be  trans- 
planted and  the  one  from  whom  one  lobe  of  the 
thyroid  gland  is  to  be  removed  are  both  anaesthetized 
simultaneously.  An*  incision  is  then  made  splitting 
one  of  the  recti  muscles  of  the  abdomen  longitudin- 
ally through  its  middle  for  a  distance  of  ten  to 
twelve  c.  m.  according  to  the  size  of  the  gland  to  be 
transplanted.     All  of  the  bleeding  vessels  are  then 


174 


THYROID    GLAND 


caught  in  haemostatic  forceps.  A  space  is  formed  by 
the  separation  of  the  rectus  abdominis  muscle  from 
the  transversalis  fascia  sufficiently  large  to  con- 
veniently hold  the  gland  to  be  transplanted,  care 
being  taken  not  to  injure  the  deep  epigastric  vein 
which  lies  between  these  structures  and  is  especially 
liable  to  injury  because  of  the  thinness  of  its  walls. 
A  pad  of  gauze  wrung  out  of  warm  normal  salt  solu- 
tion is  now  packed  into  this  space  in  order  to  control 


Fig.  23.     Shows  anterior  view  of  sarcoma  of  thyroid  gland.      (By- 
courtesy  of  Prof.  Carl  Beck.) 


the  oozing  from  the  small  vessels  by  its  pressure. 
The  salt  solution  should  not  be  warmer  than  105°  F. 
in  order  not  to  impair  these  surfaces.  Interrupted 
silkworm  gut  sutures  are  now  applied  but  not  tied, 
then  the  outer  wound  is  covered  with  gauze  and  the 
wound  is  left  until  the  gland  has  been  removed.  In 
removing  the  gland  the  technic  described  in  the 
chapter  on  thyroidectomy  should  be  followed,  great 
care  being  taken  to  handle  the  organ  with  the  great- 
est degree  of  gentleness.    It  is  at  once  placed  in  its 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  175 

new  cavity  as  soon  as  it  has  been  removed  without 
coming  in  contact  with  any  fluid,  antiseptic  or  other- 
wise. While  an  assistant  completes  the  operation  on 
the  second  patient,  the  surgeon  adjusts  the  gland 
to  the  space  between  the  rectus  abdominis  muscle 
and  transversalis  fascia  of  the  new  host  and  fastens  it 
in  this  place  at  a  few  points  with  fine  catgut  sutures 
tied  loosely  in  order  to  prevent  pressure  necrosis. 
Then  the  abdominal  wall  is  closed  with  catgut  sutures 
and  the  silkworm  gut  sutures  are  tied  over  all. 

Selection  of  Material.  Of '  course  the  same  care 
must  be  taken  in  selecting  material  that  one  would 
employ  in  the  transfusion  of  blood  from  one  individual 
to  another.  It  seems  wise  to  choose  a  healthy  in- 
dividual and  possibly  to  make  serum  tests  for  tuber- 
culosis and  syphilis  and  possibly  for  carcinoma.  It 
seems  that  a  simple  hypertrophy  would  provide  the 
best  material  and  whether  a  cystic  goitre  or  an  ex- 
ophthalmic goitre  could  properly  be  employed,  future 
experimentation  must  determine. 

That  this  operation  can  be  performed  successfully 
on  human  patients  has  been  demonstrated  by  von 
Eiselberg  and  by  Kocher.  It  has  been  suggested 
that  this  form  of  treatment  should  be  employed  in 
place  of  giving  thyroid  glands  or  thyroid  extract  in 
patients  suffering  from  myxoedema  from  any  cause 
and  in  cases  of  cretinism.  The  material  for  trans- 
plantation is  no  longer  scarce  since  the  operation  of 
thyroidectomy  has  become  so  common.  It  is  con- 
sequently to  be  expected  that  the  next  few  years  will 
demonstrate  what  can  be  expected  from  this  method. 
At  the  present  time  the  internal  use  of  preparations 
made  from  thyroid  glands  has  resulted  in  remarkable 


176  THYROID    GLAND 

improvement  in  the  growth  and  development  of 
cretins,  but  these  results  have  been  satisfactory 
rather  from  an  experimental  point  of  view  than  from 
the  standpoint  of  improving  these  patients  as  hu- 
man beings,  because  in  most  instances  they  have 
simply  been  changed  from  small  deformed  repulsive 
but  harmless  creatures  to  larger,  less  deformed,  less 
repulsive,  troublesome  imbeciles.    It  is  to  be  hoped 


Fig.  24.     Shows  lateral  view  of  sarcoma  of  thyroid  gland. 

that  better  results  may  be  obtained  by  transplanting 
thyroid  glands. 

Mr.  Lynn  Thomas,  of  Cardiff,  has  transplanted 
tissue  from  an  enlarged  thyroid  gland  removed  from 
otherwise  normal  patients  into  cavities  formed  in 
the  tibias  of  four  cretins.  In  all  of  these  patients 
thyroid  extract  had  previously  been  given  with 
benefit  but  as  soon  as  this  was  interrupted  the 
patients  became  worse.  Since  the  transplantation  of 
thyroid  gland  substance  these  patients  have  not  be- 
come worse  notwithstanding  the  fact  that  the  ad- 


OTHER  OPERATIONS  ON  THE  THYROID  GLAND  17/ 

ministration    of    thyroid    extract    was    interrupted 
permanently. 

It  does  not  seem  quite  clear  why  one  should  un- 
dertake so  tedious  an  operation  as  Thomas  has  de- 
scribed, when  experiments  in  animals  have  given 
equally  satisfactory  results  when  the  thyroid  gland 
was  transplanted  between  the  posterior  surface  of 
the  rectus  abdominis  muscle  and  the  transversalis 
fascia. 


CHAPTER  X. 


PROGNOSIS    IN   EXOPHTHALMIC   GOITRE. 


There  can  be  no  doubt  but  what  the  prognosis 
in  Graves'  disease  has  improved  enormously  during 
the  past  few  years  and  that  this  improvement  is  due 
very  largely  to  the  recognition  by  Moebius  of  the 
fact  that  the  disease  is  due  to  the  circulation  in  the 
blood  of  toxic  material  secreted  by  the  thyroid 
gland  under  certain  conditions.  Founded  upon  this 
theory  the  improvement  in  prognosis .  is  due  to 
recognition  of  the  fact  that  the  cause  of  this  intro- 
duction of  toxic  material  into  the  circulation  can 
be  stopped  by  the  removal  of  the  diseased  gland. 
That  this  can  be  done  safely  in  over  95  per  cent,  of 
all  cases  has  been  thoroughly  demonstrated. 

It  seems  likely  that  the  prognosis  in  this  disease 
will  be  still  further  improved  in  the  future,  primarily 
because  the  diagnosis  will  usually  be  made  much 
earlier  while  it  will  still  be  possible  to  obtain  a  rela- 
tive cure  of  the  patient  before  great  harm  has  been 
done,  especially  to  the  heart  muscle.  Moreover,  it 
is  to  be  expected  that  some  neutralizing  antitoxin 
will  be  introduced  which  will  make  the  thyroid 
poison  harmless  even  in  advanced  cases,  a  quality 
which  is  claimed  at  the  present  time  for  the  serum 
of  Beebe  in  early  cases  and  also  for  the  substance  de- 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE  179 

rived  by  Moebius  from  thyroidectomized  goats  to 
which  has  been  given  the  name  of  antithyroidin. 

In  a  recent  report  on  the  treatment  of  426  cases 
by  his  serum,  Beebe  expresses  his  satisfaction  with 
first  introduction  of  his  method.  He  is  carefully  ob- 
serving these  cases  and  if  they  remain  permanently 
well  for  several  years  the  method  will  undoubtedly 
receive  general  adoption.  If,  on  the  other  hand,  these 
cases  ultimately  come  to  operation,  the  latter  form 
of  treatment  will  surely  be  applied  earlier  in  these 
cases. 

There  is  undoubtedly  a  marked  difference  in  the 
gravity  of  the  prognosis  between  cases  which  begin 
slowly  and  progress  in  the  same  gradual  manner  and 
those  which  come  on  acutely  and  progress  rapidly. 
The  latter  are  far  more  grave.  But  even  these  cases 
are  not  so  absolutely  hopeless  at  present  as  they 
were  some  years  ago  since  Kocher  has  pointed  out 
a  way  of  reducing  the  absorption  by  preliminary 
ligation  of  veins  and  by  checking  the  secretion  of 
more  toxin  by  simultaneously  ligating  the  accom- 
panying arteries,  and  later  removing  one  or  more 
lobes  of  the  gland  if  necessary.  This  is  referred  to 
at  this  point  only  because  of  its  relation  to  prog- 
nosis and  has  been  fully  discussed  in  the  chapters  on 
operative  treatment.  Most  clinicians  seem  to  find 
that  the  prognosis  is  less  hopeful  in  men  than  in 
women.  Whether  this  depends  upon  the  fact  that 
men  place  greater  strain  upon  the  heart  than  do 
women  before  they  come  under  observation,  or 
upon  the  fact  that  in  men  the  heart  has  so  fre- 
quently suffered  from  the  effects  of  alcohol  or   to- 


180  THYROID    GLAND 

bacco  or  both,  or  upon  some  other  condition  it 
seems  difficult  to  determine. 

My  own  experience  bears  out  the  general  impres- 
sion that  the  disease  is  more  serious  in  men  than  in 
women.  In  a  general  way  also  the  prognosis  becomes 
more  grave  with  the  increase  in  the  age  of  the  pa- 
tient although  many  patients  quite  advanced  in 
years  have  recovered,  some  of  these  with  and  some 
others  without  surgical  treatment. 

Again  it  must  be  borne  in  mind  that  very  chronic 
cases  which  have  shown  little  or  no  change  for 
months  or  years  may  flare  up  suddenly  and  take 
upon  themselves  quite  as  violent  a  character  as  other 
cases  that  started  very  acutely  and  developed  into 
a  violent  condition  very  rapidly.  On  the  other  hand 
one  may  occasionally  encounter  one  of  these  very 
acute  violent  cases  which  will  later  take  upon  itself 
a  very  mild  chronic  condition. 

If  there  are  a  number  of  conditions  which  greatly 
depress  the  patient,  such  as  severe  diarrhoea,  violent 
sweats,  nausea,  or  extreme  weakness,  the  condition 
should  be  looked  upon  as  grave.  When  serious  heart 
symptoms  are  accompanied  by  great  emaciation  one 
should  always  give  a  guarded  prognosis.  Severe  in- 
tercurrent diseases  and  especially  severe  mental  or 
emotional  strain  make  the  prognosis  more  grave. 

In  reviewing  the  actual  statistics  of  various  au- 
thors one  is  impressed  most  forcibly  with  two  ele- 
ments. First,  that  the  immediate  results  with  all  au- 
thors have  improved  enormously  with  each  individual 
observer's  experience,  and  second  that  no  one  with 
the  exception  of  Kocher  has  even  a  considerable 
number  of  cases  that  have  been  carefully  observed 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE  181 

for  a  number  of  years  after  recovery.  This  applies  as 
well  to  cases  that  have  been  treated  with  hygiene, 
diet,  and  internal  medication  as  it  does  to  those  cases 
which  have  been  treated  by  surgical  operation. 

I  have  introduced  a  history  blank  for  use  in  these 
cases  which  when  carefully  filled  contains  all  im- 
portant facts  systematically  arranged  so  that  there 
is  uniformity  in  all  of  these  histories.  It  seems  as 
though  it  would  be  well  worth  while  to  collect  sta- 
tistics for  a  period  of  ten  years  of  all  of  these  cases 
that  are  under  treatment  by  careful  clinical  observers. 
This  would  then  serve  as  a  basis  for  reasonable  con- 
clusions. It  is  likely  that  some  other  clinicians  can 
suggest  a  much  more  complete  scheme  for  making 
such  observations  but  in  the  meantime  I  will  offer 
the  following  form: 


182  THYROID    GLAND 


HISTORY  BLANK  FOR  EXOPHTHALMIC  GOITRE   No. 

Date  of  admission Date  of  operation 

Date  of  discharge Age Sex 

Nativity Occupation 

Name Address 

Name  of  friend Address  of  friend 

Name  of  family  Dr Address  of  Family  Dr 

Diagnosis  clinical 

Diagnosis  pathological 

Family  history 

Previous  history 

Personal  history 

Date  of  first  symptoms  of  goitre 

Date  of  first  symptom  of  exophthalmic  goitre 

Exciting  cause  of  exophthalmic  goitre 

Influenced  by  adolescence? Pregnancy? 

Puerperium? Infection? 

Strain? Nervous? Mental? 

Emotional? Onset  Acute? Sub-acute? 

Gradual? Continuous? 

Intercurrent  diseases 

Symptoms  and  physical  findings,  goitre? 

Lobes  involved Degree? 

Exophthalmos? Stellwag? VonGraefe? 

Moebius? Pupils? 

Ophthalmoscopic  findings.." 

Heart 

Tachycardia? Character  of  pulse? 

General  strength? Respiration? Nutrition? 

Tremor? Muscle  spasm? 

Chorea? Mental  symptoms? 

Sweating? Pigmentation? Hypersemia? 

Anasarca? Ascites? 

Blood  H»m.? R.  B.  C W.  B.  C : 

Polymorph.    Leuc Lymph 

Trans Eos 

Urine  Sp.  gr Alb 

Sugar? Casts? 

Larnyx.    Before  Oper After  Oper 

Course  of  disease 

Course  after  operation 

Condition  when  discharged 

Condition  one  year  later 

Condition  two  years  later 

Condition  three  years  later 

Condition  four  years  later 

Condition  five  years  later 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE 


183 


GOITRE 


Before  Oper. 


After  Oper. 


Remarks 


How  long  present  

Exophthalmos    

Tachycardia 

Tremor..... 

Muscular  weakness 

Nervous  excitability 

Mental  deficiency 

Vertigo 

Graefe's  sign 

Stellwag's  sign 

Moebius'  sign 

Bryson's  sign 

Intermittent  Conditions. 

Vomiting 

Diarrhoea 

Mental  depression 

Exacerbation  upon 

Psychic  excitation 

Physical  fatigue 

Mental  fatigue 

Use  of  Thyroid  extract... 

Use  of  Iodine 

Emaciation 

Anaemia 

Myxoedema 

Oedema  eyelids 

Oedema  extremities 

Oedema  circumscribed... 
Visible  pulsation  goitre.. 

Pigmentation  skin 

Erythema. 

Blushing 

Urticaria 

Enlarged  lymph  nodes  .. 


184  THYROID    GLAND 

From  what  has  been  said  it  is  plain  that  it  would 
not  be  profitable  at  this  point  to  give  much  space  to 
the  actual  statistics  relating  to  the  prognosis  of  ex- 
ophthalmic goitre,  because  the  older  ones  are  in  no 
way  indicative  of  the  results  one  may  expect  from 
treatment  today  and  the  newer  statistics  have  no 
value  as  regards  the  most  important  question  of 
what  becomes  of  these  patients  a  considerable  num- 
ber of  years  after  the  treatment  has  ceased  in  pa- 
tients that  have  been  treated  by  various  methods. 

For  statistics  regarding  the  prognosis  of  cases 
treated  by  internal  methods  I  will  quote  Forch- 
heimer  who  has  personally  treated  56  cases  described 
in  another  chapter  of  this  book,  consisting  in  the 
administration  of  five  grains  of  hydrobromate  of 
quinine  four  times  daily  to  which  one  grain  of  ergo- 
tine  is  added  to  each  dose  if  the  quinine  alone  does 
not  give  some  relief  in  forty-eight  hours.  This  method 
has  also  been  employed  by  J.  M.  Jackson  and  L.  M. 
Mead  in  the  outpatient  department  of  the  Massa- 
chusetts General  Hospital  in  eighty-five  cases  with 
the  remarkable  result  of  76. per  cent,  cures,  13  per 
cent,  benefited  and  11  per  cent,  failures.  There  can 
be  no  doubt  but  that  operative  treatment  of  the  13 
per  cent,  that  were  benefited  but  not  cured  and  the 
11  per  cent,  that  were  failures  would  result  in  a  cure 
of  at  least  90  per  cent,  of  these  cases  so  that  first 
treating  all  of  these  cases  medicinally  until  it  can 
be  determined  which  will  be  cured  by  this  method 
and  then  treating  those  that  do  not  respond  satis- 
factorily surgically,  the  entire  mortality  will  probably 
sink  below  three  per  cent,  in  cases  not  complicated 
with  other  diseases.    This  would,  of  course,  presup- 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE  185 

pose  an  early  diagnosis  in  all  cases  and  an  early 
transfer  to  surgical  treatment  of  all  cases  not  bene- 
fited by  internal  treatment.  Any  intercurrent  dis- 
ease may,  of  course,  bring  about  a  recurrence  in 
cases  which  have  apparently  been  well  for  a  shorter 
or  longer  period  precisely  as  this  can  be  brought 
about  by  severe  fright,  unusual  physical  exertion,  or 
mental  or  emotional  strain.  Moreover,  there  can  be 
no  doubt  but  that  patients  who  have  suffered  from 
this  disease  and  have  actually  recovered  have  less 
resistance  in  case  of  any  subsequent  sickness  than 
others  who  have  not  previously  suffered  in  this  way 
even  though  there  may  be  no  recurrence  of  exoph- 
thalmic goitre  during  the  period  the  patient  suffers 
from  the  later  disease. 

Before  leaving  the  discussion  of  prognosis  of  ex- 
ophthalmic goitre  following  internal  treatment  it 
may  be  well  to  point  out  the  fact  that  the  cases  in 
which  cures  have  been  recorded  have  usually  not 
been  kept  under  observation  for  a  sufficient  number 
of  years  to  make  the  statistics  absolutely  satisfactory, 
although  in  this  result  they  are  no  more  imperfect 
than  are  the  statistics  following  surgical  operations. 
In  either  case  it  seems  of  the  greatest  importance  to 
assist  these  patients  in  planning  their  lives  so  that 
all  strain,  physical  as  well  as  mental  and  emotional 
be  eliminated  to  the  greatest  possible  extent.  This 
element  will  undoubtedly  do  much  to  improve  the 
prognosis  in  these  cases.  This  is  of  greater  import- 
ance in  cases  in  which  non-surgical  treatment  has 
been  employed  because  in  cases  having  undergone 
surgical  treatment  the  amount  of  thyroid  tissue  has 
been  reduced  to  so  marked  an  extent  that  the  flood- 


186  THYROID    GLAND 

ing  of  the  circulation  with  an  abnormal  amount  of 
thyroid  secretion  from  the  remnant  of  the  gland 
is  less  easily  accomplished  than  from  the  entire 
gland  in  cases  not  operated. 

The  prognosis  in  cases  treated  with  serum  is  still 
more  uncertain  than  in  cases  in  which  either  medical 
or  surgical  treatment  has  been  employed.  In  42 
cases  in  which  Beebe  and  Rogers  used  the  cytolitic 
serum  they  reported  18  cases  cured,  14  improved, 
6  unimproved  and  4  dead,  which  would  represent 
43  per  cent,  cured,  33.3  per  cent,  improved,  14  per 
cent,  unimproved  and  10  per  cent.  dead.  Moreover, 
it  seems  to  have  been  shown  from  the  histories  of 
these  cases  that  the  treatment  promises  success  only 
in  early  cases  in  wThich  the  thyroid  poison  has  not 
been  carried  through  the  circulation  for  a  long 
period  of  time. 

Regarding  the  prognosis  of  cases  treated  with 
Moebius  serum,  I  have  not  been  able  to  find  definite 
statistics  although  many  authors  claim  to  have  seen 
beneficial  immediate  results  from  the  use  of  this 
remedy.  In  only  one  instance  have  I  found  harmful 
effects  attributed  to  the  use  of  this  remedy,  but  on 
the  other  hand  it  has  been  impossible  to  utilize  the 
reports  either  singly  or  collectively  for  statistics. 
This  is  the  more  to  be  regretted  because  it  seems  that 
we  must  expect  ultimately  to  secure  relief  for  pa- 
tients suffering  from  exophthalmic  goitre  from  this 
direction.  It  seems  as  though  it  must  be  possible 
to  find  some  antibody  that  will  neutralize  the  thyroid 
poison  until  the  hyperactive  gland  portions  have 
finished  their  abnormal  activity.  So  far  Beebe's 
serum  seems  to  represent  the  nearest  approach  to 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE  187 

this  end,  but  not  near  enough  to  be  depended  upon. 
Many  other  conditions  undoubtedly  have  a  marked 
bearing  upon  the  prognosis  in  patients  suffering  from 
exophthalmic  goitre.  A  man  who  is  able  to  earn  a 
livelihood  for  himself  and  his  family  only  by  hard 
labor  and  who  feels  the  responsibility  of  the  support 
of  those  who  are  dependent  upon  him  has  a  much 
less  hopeful  prognosis  than  a  man  who  has  no  re- 
sponsibilities and  is  not  compelled  to  exert  himself 
either  physically  or  mentally. 

In  the  same  way  women  with  great  domestic  or 
social  responsibilities  have  a  grave  prognosis.  Those 
who  are  active  in  the  social  world  cannot  obtain  rest 
if  they  remain  at  home  and  if  they  seek  rest  at  re- 
sorts or  sanitoria  their  habits  of  life  usually  prevent 
them  from  obtaining  the  necessary  rest  and  con- 
sequently they  usually  return  home  in  a  worse  con- 
dition than  was  present  when  they  left.  Again,  it 
seems  that  patients  amenable  to  treatment  with  sug- 
gestion give  a  better  prognosis  in  a  general  way  than 
others  not  so  constituted.  Moebius  suggests  that  this 
accounts  for  the  fact  that  so  many  relatively  inactive 
remedies  have  received  so  much  praise  in  the  treat- 
ment of  this  disease.  So  long  as  the  remedy  does  no 
harm  and  the  physician  and  patient  believe  in  its 
usefulness  the  latter  receives  the  benefit  of  mental 
and  physical  rest  and  his  condition  is  improved  as  a 
result  of  this  rest. 

So  far  as  the  prognosis  of  cases  of  exophthalmic 
goitre  treated  surgically  is  concerned  one  can  pre- 
dict with  certainty  that  none  of  the  existing  statistics 
will  have  any  value  even  after  a  few  decades  because 
of  a  number  of  conditions  already  referred  to.    I  will 


188  THYROID    GLAND 

consequently  give  only  the  statistics  of  a  few  very 
widely  separated  authors  who  are  at  the  same  time 
the  best  authorities  on  the  subject.  I  refer  to  C.  H. 
Mayo,  of  America;  Kocher,  of  Switzerland  and 
Landstrom,  of  Sweden,  although  a  score  of  others, 
like  Halstead,  Shephard,  Curtis,  Mikulicz,  Rehn  and 
others,  have  published  lists  of  cases  which  are  both 
interesting  and  instructive. 

Kocher 's  statistics  show  a  mortality  of  3.5  per 
cent,  in  cases  operated  for  the  relief  of  exophthalmic 
goitre.  This  includes  both  early  and  late  cases  al- 
though if  grouped  separately  the  cases  operated 
during  the  past  few  years  would  give  a  much  smaller 
mortality.  He  states  also  that  there  is  not  a  single 
case  in  which  the  patient  has  not  been  much  bene- 
fited. In  83  per  cent,  of  cases  a  cure  is  reported.  73  per 
cent,  of  cases  with  primary  disease  were  cured  and 
92  per  cent,  of  cases  with  the  disease,  combined  with 
ordinary  goitre  were  cured.  100  per  cent,  of  cases 
with  vascular  goitres  were  cured. 

The  statistics  of  C.  H.  Mayo  vary  so  little  from 
those  given  above  that  it  seems  scarcely  necessary 
to  repeat  them.  Suffice  it  to  say  that  the  mortality 
is  less  than  3  per  cent,  in  an  experience  based  on 
more  than  1,000  thyroidectomies  for  the  relief  of 
exophthalmic  goitre.  Landstrom's  statistics  based  on 
54  cases  show  very  similar  immediate  results.  He 
has  subjected  the  histories  of  his  cases  to  a  most 
critical  study  from  every  point  of  view  which  makes 
his  observations  especially  interesting  and  valuable, 
although  the  relatively  small  material  makes  his 
conclusions  lacking  somewhat  in  clinical  support 
compared  to  the  above  authors. 


PROGNOSIS    IN    EXOPHTHALMIC    GOITRE  189 

Landstrom  has  shown  from  a  most  careful  study 
of  his  cases  that  there  is  little  postoperative  improve- 
ment from  actual  injury  to  the  heart  as  a  result  of 
the  thyroid  poisoning  even  in  cases  that  seem  to 
have  recovered  as  a  result  of  thyroidectomy.  Al- 
though the  tachycardia  may  subside  there  seems  to 
be  but  little  reduction  in  the  size  of  the  heart  if 
dilatation  has  occurred  as  a  result  of  the  disease,  so 
that  we  can  speak  only  of  a  relative  cure.  Although  a 
man  may  work  after  he  has  obtained  such  a  relative 
cure  as  a  result  of  thyroidectomy,  still  the  prognosis 
cannot  be  good  in  such  a  case  as  compared  with 
recovery  from  many  other  diseases  in  which  the 
tissues  have  not  been  exposed  to  this  toxic  sub- 
stance. No  doubt  a  long  period  of  rest  following 
thyroidectomy  will  enable  the  tissues  to  recuperate 
to  a  marked  extent  although  such  defects  as  cardiac 
dilatation  may  not  be  overcome  by  the  natural 
tendency  of  the  tissues  to  recover  under  favorable 
conditions  when  the  cause  of  their  pathological 
changes  has  disappeared. 

All  symptoms  which  are  due  to  the  direct  irrita- 
tion of  the  thyroid  toxin  are  certain  to  improve  after 
thyroidectomy  has  eliminated  the  possibility  of 
further  production  of  this  toxin,  but  it  is  quite 
different  with  the  symptoms  that  depend  upon  actual 
degenerative  processes  like  cardiac  dilatation  due 
to  myocarditis.  The  same  is  true  of  marked  exoph- 
thalmos. Although  the  muscles  involved  in  the 
production  of  the  exophthalmos  may  recover  to  a 
great  extent  in  some  cases,  in  others  they  will  remain 
in  a  weakened  condition  and  consequently  the  symp- 
toms may  remain  although  no  fresh  poison  is  in- 
troduced into  the  circulation. 


190  THYROID   GLAND 

It  is  an  easy  matter  to  determine  the  fact  of  a 
permanent  impairment  of  the  heart  muscles  and  the 
cylinder-formed  muscle  of  Landstrom  which  de- 
termines the  exophthalmos,  but  it  is  much  less  easy 
to  determine  the  permanent  effect  of  exophthalmic 
goitre,  which  has  persisted  for  a  considerable  period 
of  time,  upon  the  other  tissues  of  the  body.  It  is 
however,  clear  that  the  effect'  is  not  confined  to  any 
muscle  or  groups  of  muscles  but  that  all  tissues  of 
the  body  suffer.  The  form  of  history  proposed  above 
will  serve  to  give  us  data  for  reliable  conclusions, 
provided  a  careful  record  is  made  in  each  case  ac- 
cording to  this  form,  and  some  provision  is  made  for 
annual  reports  from  patients  after  recovery. 

In  the  meantime  we  know  enough  to  be  entitled 
to  the  opinion  that  the  hyperthyroidism  must  be 
'stopped  early  in  order  to  prevent  these  permanent  de- 
fects. If  this  can  be  accomplished  with  rest,  hygiene, 
diet,  and  therapy,  well  and  good,  if  not,  then  the  case 
should  be  treated  surgically.  At  this  point  it  is  well 
again  to  insist  upon  the  fact  that  whatever  form  of 
treatment  may  be  employed,  all  that  can  be  expected 
primarily  of  this  treatment  is  to  stop  the  progress  of 
the  poisoning. 

The  repair  of  the  harm  that  has  already  been 
done  to  the  tissues  must  be  accomplished  by  the 
after  treatment  which  will  have  to  consist  of  rest 
tonics,  diet  and  general  hygiene.  This  is  quite  as  im- 
portant after  surgical  as  after  internal  treatment. 
In  either  case  this  after-treatment  must  be  continued 
for  many  months  and  this  will  largely  determine  the 
ultimate  prognosis. 


CHAPTER  XL 


HEREDITY   IN   GOITRE. 


Heredity.  The  fact  is  well  known  that  in  innu- 
merable cases  one  or  both  parents  and  a  number  of 
the  children  and  again  in  turn  their  children  have 
suffered  from  goitre.  This  has  been  observed  as  far 
back  as  the  disease  itself.  Whether  this  indicates 
that  the  offspring  have  inherited  the  disease  or  a 
tendency  for  its  development,  or  simply  that  the 
same  conditions  and  habits  have  caused  the  same 
disease  in  the  offspring  that  similar  conditions 
brought  about  in  the  parent  is  much  more  difficult 
to  determine.  It  is  true  that  in  communities  in  the 
United  States  in  which  large  numbers  of  Swiss  im- 
migrants have  established  their  homes,  the  number 
of  goitres  in  the  children  born  and  reared  in  America 
is  very  small  compared  with  the  number  in  the  par- 
ents. But  this  again  is  not  a  sufficient  test  because 
these  children  may  have  inherited  a  tendency  to  the 
development  of  goitre  which  under  favorable  con- 
ditions would  have  developed  this  disease  quite  to 
the  extent  it  developed  in  the  parents,  but  under 
the  unfavorable  conditions  in  which  the  child  was 
placed  in  America  for  the  development  of  this  dis- 
ease the  simple  tendency  inherited  from  the  parent 
did  not  suffice  to  produce  the  disease.  It  is  rare  to 
encounter  a  goitre  in  a  patient  in  whom  one  cannot 


192 


Thyroid  gland 


find  the  disease  in  some  ancestor  or  near  blood  rela- 
tive by  carefully  investigating  the  family  history. 

As  regards  heredity  in  exophthalmic  goitre  there 
seems  to  be  more  opposition  than  to  the  theory  of 
heredity  in  simple  goitre. 

The  most  satisfactory  case  I  have  encountered  in 


Fig.  25. 
turret  head. 


Infant   of   5   months  shows  distinct  exophthalmos  and 


the  literature  is  one  described  by  Schmauch,  in  a 
woman  thirty-five  years  of  age,  mother  of  four 
children,  the  last  one  born  eight  weeks  prematurely. 
At  the  time  the  different  children  were  born  the 
mother  was  twenty-six,  twenty-eight,  thirty  and 
thirty-two  years  old.    The  goitre  first  appeared  dur 


HEREDITY    IN    GOITRE  193 

ing  the  second  half  of  the  first  pregnancy  and  in- 
creased during  each  succeeding  pregnancy.  Distinct 
symptoms  of  exophthalmic  goitre  developed  during 
her  fourth  pregnancy.  She  had  marked  exophthal- 
mos, was  cyanotic,  had  oedema  over  the  entire  body, 
was  extremely  weak,  had  a  pulse  of  145  beats  per 
minute,  and  the  neck  measured  40  c.  m.  Three  days 
after  labor  she  was  subjected  to  treatment  with 
Moebius'  anti-thyroidin,  thirty  drops  twice  daily, 
every  second  day.  The  dose  was  later  increased  to 
fifty  drops  twice  daily,  every  second  day,  and  then 
again  reduced   to   twenty   drops. 

She  improved  steadily,  increased  in  weight  from 
114  to  138  pounds.  The  pulse  was  reduced  so  that 
it  varied  from  90  to  110  beats  per  minute,  while  the 
average  count  had  been  about  35  beats  higher  during 
the  severe  attack,  and  her  general  condition  was 
greatly  improved. 

The  youngest  child,  a  boy,  born  during  the  height 
of  her  attack,  weighed  scarcely  four  pounds  at  birth. 
Fig.  25  represents  him  at  the  age  of  five  months. 
His  head  is  irregular  in  shape,  his  abdomen  is  large, 
his  eyes  are  protruding  and  there  is  distinct  irregu- 
larity in  the  growth  of  the  forehead.  The  occuput 
and  forehead  were  bulging  out,  the  parietal  bones 
were  sunken,  giving  the  child's  head  the  form  of 
a  saddle  head  and  turret  head  at  this  age,  a  con- 
dition which  has  persisted  to  the  present  time  to 
quite  a  marked  extent  as  shown  in  Figs.  27  and  28. 
Five  weeks  after  labor  his  eyes  started  to  bulge  out 
and  the  head  as  a  whole  seemed  to  grow  rapidly, 
especially  the  forehead.  A  few  days  later  the  temporal 


194  THYROID    GLAND 

bone  began  to  protrude,  then  one  side  of  the  occiput, 
then  the  other  side,  then  the  left  frontal  bone  in  the 
region  of  the  protuberance  seemed  to  elevate. 


Fig.  26.      Front  view  at  age    of  5   months   of   infant   shown   in 
Fig.  25. 

These  peculiarities  are  all  shown  in  Figs.  25  and 
26.  At  the  age  of  11  months  the  child  weighed  19j 
pounds,  at  the  age  of  27  months  his  height  is  80  c.  m., 
he  weighs  35  pounds  and  his  appearance  is  shown 
in  Figs.   27  and  28,  which  still  shows  plainly  the 


HEREDITY    IN    GOITRE 


195 


presence  of  exophthalmos.  The  conditions  observed 
in  this  child  seem  to  show  that  exophthalmic  goitre 
is  sometimes  transmitted  from  mother  to  child.  It 
would  lead  too  far  should  we  go  into  discussion  more 
extensively   at  this   point   but   for   those   who   are 


Fig  27.     Front  view  at  age  of  27  months;  the  exophthalmos  shows 
distinctly. 

especially  interested  in  this  feature,  a  study  of  the 
essay  by  Schmauch,  will  furnish  exceedingly  inter- 
esting and  profitable  reading.  In  most  instances  in 
which  authors  mention  the  condition  of  children 
born  of  exophthalmic  mothers  there  has  been  no 


196 


THYROID    GLAND 


transmission  of  this  condition  from  the  mother  to 
the  child. 

Congenital  Goitre.  .    A  large  number  of  cases  has 
been  reported  of  infants  born  with  goitres  varying 


Fig.  28.     At  age  of  27  months  greatly  improved  in  every  respect 
but    exophthalmos   is   still    present. 


in  size.  These  usually  decrease  in  size  rapidly  after 
birth  or  the  infants  die  in  convulsions  or  exhaustion. 
Oswald  has  found  that  young  calves  have  no  iodin 
in  their  thyroids,  but  that  after  nursing  and  before 
taking  other  food  iodin  is  found,  hence,  he  reasons 


HEREDITY    IN    GOITRE  197 

that  the  milk  must  contain  iodin  unless  this  comes 
from  the  blood  of  the  young  animal  bringing  this 
substance  from  other  tissues  in  the  body.  It  is  pos- 
sible that  mother's  milk  supplies  the  iodin  in  infants 
with  congenital  goitre. 

In  an  infant  in  which  the  neck  had  a  circumference 
of  8  c.  m.  more  than  the  head,  due  to  congenital 
goitre,  which  became  slightly  worse  during  the  first 
two  weeks  of  life,  I  have  seen  the  goitre  decrease 
perceptibly  from  day  to  day  by  the  administration  of 
5  grs.  of  thyroid  extract  three  times  daily  to  the 
mother  and  \  gr.  twice  daily  to  the  infant.  In  four 
weeks  the  little  patient  was  in  excellent  health  and 
when  two  months  old  nothing  of  the  former  disease 
could  be  detected. 


PART  II. 


THE  PARATHYROID  GLANDULES 


CHAPTER  XII. 


INTRODUCTION— HISTORICAL— FUNCTION. 


Tucked  away  behind  the  more  prominent  thyroid 
gland  the  parathyroid  glandules  for  a  long  time  es- 
caped the  eye  of  the  anatomist,  and  even  for  a  long 
time  after  they  were  finally  discovered  they  were 
given  no  particular  consideration.  Finally  a  French 
investigator  noted  that  a  rabbit  deprived  of  these 
tiny  bodies  died  in  tetany.  Gradually  the  import- 
ance of  this  observation,  through  the  extensive  con- 
firmation of  animal  investigation,  dawned  upon  the 
surgeon  and  the  practitioner  of  medicine. 

The  anatomist,  the  histologist,  and  the  embryolo- 
gist  had  proven  these  bodies  to  possess  a  structure 
different  from  that  of  any  other  tissue.  The  ex- 
perimental investigator  had  shown  their  remark- 
able physiologic  importance  in  a  wide  range  of 
animals,  and  demonstrated  that  they  were  an  inde- 
pendent vital  organ.  It  remained  for  the  clinician 
to  take  these  results  and  apply  them  at  the  bed  side 
and  in  the  operating  room.  There  was  the  whole 
range  of  tetanies  to  be  considered,  some  of  especial 


200  PARATHYROID    GLANDS 

interest  to  the  internist  and  others  to  the  neurologist ; 
some  of  importance  to  the  gynaecologist  and  ob- 
stetrician. To  the  surgeon  there  was  at  once  the 
question  of  the  importance  of  these  bodies  in  opera- 
tions involving  the  thyroid  gland.  All  diseases  that 
manifested  tetanic  symptoms  came  at  once  into 
consideration  in  the  light  of  this  new  discovery. 

Many  of  these  diseases  for  which  a  hypoparathy- 
roid  etiology  was  first  suggested  have  lacked  in  post 
mortem  morphologic  findings,  but  a  group  of  tetanies 
has  remained  that  may,  by  their  study  from  the 
standpoint  of  a  parathyroid  etiology,  be  brought 
into  a  closer  relation. 

To  the  surgeon  the  relation  of  tetany  to  parathy- 
roid destruction  has  been  so  definitely  proven  that 
ultimately  an  exact  acquaintance  with  these  struc- 
tures must  be  a  part  of  all  intimate  surgical  knowl- 
edge. Such  knowledge  has  been  delayed,  save  with 
the  leaders  of  surgery,  owing  to  the  natural  skepti- 
cism that  would  for  a  long  time  be  maintained  to- 
wards the  striking  phenomenon  of  the  removal  of 
such  small  bodies  giving  rise  to  so  severe  and  often 
fatal  tetany.  But  at  the  present  time  the  truth  is 
coming  to  be  generally  recognized,  and  the  parathy- 
roid glands  are  being  given  the  place  of  real  import- 
ance that  they  deserve. 

The  assembling  of  all  that  is  known  about  the 
parathyroids  is  not  an  easy  task,  for  it  must  be  sought 
from  many  sources.  So  far  there  has  been  little 
regard  paid  to  these  glands  by  the  writers  of  text 
books,  but  this  disregard  is  not  due  to  lack  of  work 
on  these  bodies.  Considerably  more  than  three 
hundred,  titles  may  be  collected  of  important  articles 


INTRODUCTION HISTORICAL FUNCTION 


201 


dealing  with  these  glands  from  laboratory  workers 
in   Sweden,    Germany,    France,  Italy  and  America. 


HISTORICAL. 


It  was  in  the  year  1880  that  Ivar  Sandstrom  dis- 
covered the  parathyroid  glands.  He  found  these 
bodies  constant  in  fifty  autopsies  in  man,  and  he 
further  studied  them  in  the  dog,  cat,  rabbit,  ox  and 
horse.  This  work  of  Sandstrom' s  is  so  thorough  and 
complete  from  both  an  anatomic  and  a  histologic 
standpoint  that  he  deserves  all  credit  for  the  discov- 
ery. It  will  only  add  to  the  thoroughness  of  Sand- 
stroem's  work  to  cite  a  number  of  investigators  be- 
fore him  who  had  noted  these  glandules  but  passed 
them  by  as  being  probably  accessory  thyroids  or 
small  lymph  nodes. 

Remak  is  cited  by  Sandstrom  as  having  described 
these  bodies.  Virchow,  in  1863,  also  noted  them, 
as  he  described  small  rounded  bodies,  about  the  size 
of  a  pea,  which  he  found  in  the  loose  connective 
tissue  on  the  posterior  surface  of  the  lateral  thyroid 
lobes,  but  he  thought  these  bodies  were  lymph  nodes 
or  detached  portions  of  thyroid  tissue. 

Baber,  in  1876,  described  what  we  now  know  are 
the  parathyroid'  glands  of  the  dog,  and  the  same 
author,  independently  of  Sandstrom,  published  in 
1881  a  description  of  what  he  termed  "undeveloped 
portions  of  the  thyroid  gland"  which  were  undoubt- 
edly parathyroids,  but  he  failed  to  recognize  their 
constant  occurrence  or  significance. 

Among  other  investigators  who  failed  to  recognize 
the  significance  of  these  bodies,  although  undoubtedly 


202  PARATHYROID  GLANDS 

observing  them,  may  be  mentioned  Kaydi,  and 
Maselung,  whose  observations  were  published  two 
years  and  one  year  respectively  before  Sandstrom 's 
paper  appeared.  Immediately  after  Sandstrom, 
Woelfler  described  under  the  name  "Glandulae  Para- 
thyreoideae"  (the  same  term  that  had  been  used  by 
Sandstrom),  similar  bodies  which  he  considered  as 
an  embryonal  developmental  stage  of  thyroid  tissue 
set  free  from  the  gland  at  an  early  time. 

From  this  time  on,  the  parathyroid  glandules,  as  we 
will  now  term  them,  received  more  or  less  spasmodic 
attention.  Rogowitz,  in  1888,  described  what  he 
called  "restes  embryonnaires"  in  the  thyroid  glands  of 
animals.  He  considered  them  as  parts  of  the  thyroid 
in  process  of  development.  Christian!,  in  1893,  ex- 
amined the  parathyroids  of  rodents,  finding  only  one 
glandule  on  each  side.  This  author  also  considered 
these  organs  as  portions  of  embryonic  thyroid  tissue. 
Liezenska,  described  these  glands  in  the  dog,  and 
considered  the  tissue  a  sort  of  reserve  material  that 
could  furnish  fresh  thyroid  follicles  when  necessary. 

Huerthle,  at  about  this  time,  described,  in  a 
study  of  thyroid  secretion,  an  "interfollikulaeres  Epi- 
thel,"  which  differed  in  its  structure  from  thyroid 
and  secreted  no  colloid  substance.  He  considered 
this  tissue  as  undeveloped  thyroid. 

It  was  not  until  1895  that  Kohn  placed  the  ana- 
tomy and  histology,  as  well  as  the  genesis  of  these 
glandules,  on  a  definite  basis  and  established  the 
fact  that  they  were  independent  structures  morphol- 
ogically and  functionally  distinct  from  the  thyroid 
gland.  He  also  made  clear  the  fact  that  in  the  rabbit 
there  were  two  pairs  of  these  glandules.     The  defi- 


INTRODUCTION HISTORICAL FUNCTION         203 

nite  establishment  of  the  number  and  situation  of 
these  glands  in  the  dog,  cat  and  rabbit  by  Kohn  was 
of  great  importance  to  the  development  of  the  physi- 
ologic importance  of  these  structures. 

Next  to  the  name  of  Sandstrom  that  of  Gley  is 
most  intimately  associated  with  the  development  of 
our  knowledge  of  the  parathyroid  glands.  In  a 
series  of  fifteen  papers  appearing  for  the  most  part 
as  short  communications  in  the  Comptes  Rendus  de 
la  Societe  de  Biologie  from  1891  to  1897,  Gley  es- 
tablished for  the  first  time  by  animal  experimenta- 
tion the  important  physiological  function  of  the 
parathyroid  glandules  and  showed  that  post  operative 
tetany  after  thyroid  operation  was  due  wholly  to  re- 
moval of  the  parathyroids,  and  was  in  no  way  connect- 
ed with  the  thyroid  as  had  previously  been  supposed. 

These  organs,  then,  that  for  a  long  time  had  ap- 
peared so  comparatively  unimportant  from  an  ana- 
tomic standpoint,  and  which  presented  so  peculiar  a 
histologic  picture  as  to  make  the  idea  possible  that 
they  were  rudimentary  rather  than  functional  or- 
gans, were,  by  the  work  of  this  investigator  shown 
to  possess,  when  regarded  from  an  experimental 
side,  an  importance  in  the  vital  economy  equal  to 
that  of  any  other  functioning  organ.  And  it  is  from 
the  time  of  Gley  that  the  question  of  this  important 
•function  of  these  tiny  glands  has  aroused  the  interest 
of  the  medical  and  surgical  world,  and  the  literature 
has  multiplied  in  the  effort  to  solve  the  complicated 
problems  that  the  parathyroid  glandules  have  pre- 
sented to  us. 

Among  the  earlier  investigators  who  took  up  and 
added  to  the  work  of  Gley  in  establishing  the  fact 


204  PARATHYROID    GLANDS 

that  the  loss  of  all  the  parathyroid  glands  results  in 
death  in  tetany  there  are  certain  names  of  historical 
interest  which  may  be  mentioned  here,  though  their 
work  will  be  taken  up  in  more  detail  in  considering 
the  physiology  of  these  glands. 

This  list  includes  Verstraten  and  Vanderlinden  in 
Belgium,  Vassale  and  Generali  in  Italy,  Edmunds 
and  D.  A.  Welsh  in  England,  Kohn,  Pineles  and 
Erdheim  in  Austria,  Moussu  and  Alquier  in  France, 
and  MacCallum  in  America. 

The  animals  used  for  these  experiments  include  the 
dog,  cat,  rabbit,  rat  and  monkey,  all  of  which  ani- 
mals respond  to  the  complete  removal  of  the  para- 
thyroids by  severe  tetanic  symptoms  ending  usually  in 
death.  In  the  herbivora  it  seemed  impossible  to  show 
at  first  this  parathyroid  tetany  after  operation,  and  it 
was  thought  the  differences  in  these  animals  was  due 
to  their  vegetable  diet,  but  even  in  such  animals  as 
the  sheep  and  goat,  tetany,  it  was  found,  could  be 
produced  provided  all  parathyroid  tissue  was  re- 
moved, the  difficulty  being  to'  find  the  parathyroid 
tissue  which  apparently  has  a  wide  distribution  in 
these  animals. 

The  natural  result  of  this  experimental  work  in 
animals  was  a  flow  of  ideas  towards  its  application  to 
certain  conditions  of  importance  from  a  clinical 
standpoint  in  the  practice  of  surgery  and  internal 
medicine. 

The  pathologist,  it  might  be  mentioned  in  passing, 
found  little  to  repay  him  for  a  morphologic  study  of 
these  glands,  although  certain  facts  of  interest  and 
some  observations  of  negative  as  well  as  positive 
importance  have  been  brought  out  by  the  studies  of 


INTRODUCTION HISTORICAL FUNCTION         205 

Peterson,  Benjamins,  MacCallum,  Getzowa,  Erdheim 
and  others  as  will  be  duly  chronicled. 

To  the  internist  the  question  of  a  hypoparathy: 
roid  etiology  in  the  various  tetanies  became  of  in- 
terest; such  as  the  so-called  idiopathic  tetany  of 
workers  in  certain  lines,  children's  tetany,  the  tetany 
of  pregnancy  and  lactation,  and  gastric  tetany.  Epi- 
lepsy, exophthalmic  goitre,  paralysis  agitans  and 
other  conditions  attended  with  tremor  have  had  their 
turn  as  diseases  for  which  a  hypoparathyroid  etiol- 
ogy was  tentatively  advanced.  Osteomalacia  and 
rickets  interest  us  as  being  possibly  associated  in 
some  way  with  changes  in  the  parathyroid  secretion. 
Moreover  there  yet  remains  a  variety  of  chronic  nu- 
tritional disturbances,  associated  with  marked  dimin- 
ished resistance  to  bacterial  infection,  to  be  carefully 
considered  as  bound  up  in  some  manner  with  lack 
of  parathyroid  substance. 

It  is  to  the  surgeon,  however,  that  these  glands 
have  appealed  most  strongly  on  account  of  the  ques- 
tion of  post-operative  tetany  in  connection  with 
thyroid  surgery.  Such  tetany  was  not  unknown  to 
the  earlier  surgeons.  Billroth,  Reverdin  and  Miku- 
licz had  a  high  per  cent  of  tetanies  following  complete 
thyroidectomies  in  the  early  eighties  and  before. 
But  based  on  the  knowledge  that  it  was  the  parathy- 
roid and  not  the  thyroid  removal  that  was  responsible 
for  this  tetany,  the  technic  of  modern  thyroid  opera- 
tions, has  practically  obviated  such  untoward  results. 

Today  perhaps  the  greatest  interest  centers  around 
the  question  of  parathyroid  therapy,  i.  e.,  the  matter 
of  making  good  a  loss  of  parathyroid  tissue  or  con- 
trolling tetany  after  parathyroidectomy  by  the  feed- 


206  PARATHYROID    GLANDS 

ing  of  parathyroids  or  the  use  of  gland  extracts,  or 
by  the  transplantation  of  parathyroid  glands,  or  by 
the  use  of  calcium  salts  as  recommended  by  Parhon 
and  Urechie  in  1907,  and,  independently,  by  MacCal- 
lum  and  Voegtlin  in  1908. 

In  detailing  the  main  facts  regarding  the  parathy- 
roid glands  in  this  brief  outline  it  may  be  mentioned 
that  they  have  not  been  brought  forward  without 
considerable  conflicting  opinion,  both  as  to  the  func- 
tion, the  importance,  and  the  independence  of  these 
bodies. 

A  critical  examination  of  the  literature,  however, 
masses  the  weight  of  evidence  not  only  physiologi- 
cally and  experimentally,  but  anatomically  as  well, 
in  favor  of  the  view  that  the  parathyroid  glandules 
are  in  no  way  associated  with  the  thyroid  sav£  for 
the  relationship  of  anatomical  propinquity  and  that 
functional  relationship  (which  may  in  certain  in- 
stances be  more  intimate  than  we  suppose)  which 
must  exist  in  normal  man  and  animals  between  all 
important  glands  which  have  to  do  with  internal 
secretion.  In  a  careful  survey  of  the  literature  we 
have  failed  to  find  any  convincing  proof  that  the 
parathyroids,  either  in  structure  or  function,  have 
even  served  vicariously  for  the  thyroid  gland  or  are 
in  any  way  to  be  considered  rudimentary  thyroids. 
They  are  to  be  considered  independent  vital  organs, 
as  necessary  to  the  existence  of  an  individual  as  the 
liver,  the  suprarenal  glands,  or  any  other  organ  whose 
function  is  indispensable  in  the  maintenance  of 
life. 

As  to  the  part  played  by  the  parathyroids  in  the 
body,  we  can  only  say  that  their  complete  removal, 


INTRODUCTION — HISTORICAL — FUNCTION         207 

as  has  been  practiced  so  many  times  in  a  wide  variety 
of  animals,  leads  to  death  with  severe  symptoms  of 
tetany  which  is  in  no  way  associated  with  or  depend- 
ent on  the  thyroid  gland  as  was  once  thought.  We 
also  know  that  by  their  gradual  complete  destruc- 
tion, severe  nutritional  disturbances  may  be  brought 
about  ending  in  death  in  apathy,  with  no  symptoms 
of  tetany.  When  destruction  is  nearly,  but  not  quite 
complete,  transitory  symptoms  of  tetany  may  appear 
for  a  time  and  then  subside ;  the  theory  being  that 
some  small  islet  of  parathyroid  tissue  left  behind  has 
undergone  compensating  hypertrophy  sufficient  to 
maintain  the  life  of  the  animal.  Thus  it  seems  that 
we  are  wonderfully  safeguarded  by  a  rich  abundance 
of  over  supply  and  that  even  though  at  a  goitre  oper- 
ation three  of  the  four  glandules  were  accidentally 
removed  there  would  be  no  untoward  symptoms  if 
the  remaining  glandule  was  fairly  normal.  In  rab- 
bits it  is  stated  that  seven-eighths  of  the  parathyroid 
substance  must  be  removed  in  order  to  produce  the 
characteristic  toxemia,  and  we  know  that  fatal 
tetanic  symptoms  never  develop  in  dogs  that  possess 
a  single  parathyroid  gland. 

While  the  exact  mechanism  by  means  of  which 
the  symptoms  of  tetany  are  brought  about  following 
the  loss  of  the  parathyroid  glands  is  still  open  to 
investigation,  it  may  be  stated  that  there  are  two 
main  hypotheses;  first,  the  idea  that  a  metabolic 
toxin  (which  under  normal  conditions  is  neutralized 
by  the  parathyroid  secretion)  gives  rise  to  the  symp- 
toms; and  second,  that  the  symptoms  are  due  to  a 
diminution  of  calcium  in  the  tissues  (which  has  been 
shown  to  follow  parathyroid  removal),  the  with- 
drawal of  which  leaves  the  nerve  cells  in  a  state  of 


208  PARATHYROID    GLANDS 

hyperexcitability  which  expresses  itself  in  tetany. 
While  there  is  some  question  as  to  the  fact  that  such 
a  condition  as  exists  in  the  second  hypothesis  is 
present  following  the  removal  of  the  parathyroid 
glands,  nevertheless  the  administration  of  a  soluble 
calcium  salt  will  promptly  check  the  symptoms  of 
tetany.  It  is  a  mooted  question  at  present  as  to 
whether  this  calcium  deficiency  is  always  present 
after  parathyroidectomy. 

That  a  poison  is  circulating  in  the  blood,  following 
parathyroid  removal,  seems  to  be  shown  by  the  fact 
that  symptoms  may  be  controlled  for  a  time  by 
bleeding  and  transfusing  an  animal  with  normal 
blood.  Moreover,  as  PfeirTer  and  Mayer  have  demon- 
strated, while  the  serum  of  a  parathyroidectomized 
animal  will  not  produce  symptoms  of  tetany  in 
a  normal  animal,  it  does  bring  on  these  symptoms 
in  an  animal  that  has  suffered  partial  removal  of 
the  parathyroid  glands. 

In  concluding  this  chapter  it  may  be  noted  that 
there  has  been  more  or  less  lack  of  unity  in  the 
nomenclature  of  these  organs.  Sandstroem  first 
designated  the  bodies  "Glandulas  Parathyreoideas," 
Gley  used  the  term  "Glandules  Thyroidiennes;"  Hof- 
meister,  "Nebenschilddruesen;"  Zielinska,  "Acces- 
sorische  Schilddruesen;"  von  Jacoby  and  Blumreich, 
"Nebendruesen;"  von  Tourneux  and  Verdun,  "Glan- 
dules Thymiques."  Kohn  originated  the  term  "Epi- 
thelkoerperchen,"  which  is  still  used  more  or  less 
extensively  by  German  writers,  and  Verebely  ex- 
tends this  to  "Branchiale  Epithelkoerperchen."  By 
most  writers  these  organs  are  today  generally  des- 
ignated the  "Parathyroid  Glands,"  or  "Glandules." 


CHAPTER  XIII. 


ANATOMY. 


Normally  there  are  present  in  man  four  parathy- 
roid glandules,  situated  on  the  posterior  surface  of 
the  lateral  lobes  of  the  thyroid,  two  on  either  side, 
one  above  and  behind  the  other,  and  separated  from 
the  thyroid  by  connective  tissue.  While  the  position 
of  these  glandules  may  vary,  the  variation  is  within 
certain  definite  limits,  so  that  the  position  is  fairly 
constant.  The  superior  (external)  glandules  are 
more  constant  in  position  than  the  inferior  (internal) 
glandules.  They  (the  superior)  are  usually  found, 
one  on  each  side,  on  the  posterior  wall  of  the  oesoph- 
agus, at  the  posterior  edge  of  the  lateral  thyroid 
lobes,  about  opposite  the  cricoid  cartilage  midway 
between  the  upper  and  lower  poles  of  the  thyroid. 
The  height  may  vary,  the  superior  glandules  have 
been  found  as  high  as  the  inferior  cornu  of  the  thy- 
roid cartilage..  They  are  usually  wholly  outside  the 
thyroid,  but  they  may  be  found  within  the  capsule 
of  this  organ.  The  inferior  thyroid  artery  and  re- 
current laryngeal  pass  up  in  front  and  internally  to 
the  glandules,  and  the  superior  bodies  can  usually 
be  found  at  the  entrance  of  the  end  branches  of  the 
inferior  thyroid  artery. 


210  PARATHYROID    GLANDS 

The  inferior  (internal)  parathyroids  are  anterior 
to  the  upper  bodies,  lie  always  in  front  of  the  inferior 
thyroid  artery,  and  are  usually  about  opposite  the 
lower  pole  of  the  thyroid,  though  they  may  be  found 
as  low  as  the  fourteenth  tracheal  ring.  They  may 
be  either  postero-lateral  or  antero-lateral  to  the 
thyroid  or  may  be  at  some  distance  from  the  thyroid 
(usually  below  it)  imbedded  in  fat  and  areolar  tissue. 
The  fact  that  the  inferior  glandules  are  found  less 
constantly  than  the  superior  is  due  to  their  incon- 
stant position,  and  the  difficulty  in  distinguishing 
them  from  small  lymph  nodules,  pieces  of  thymus 
tissue,  fat,  and  accessory  thyroid  nodules  that  may 
be  found  in  this  locality. 

The  parathyroids  are  rarely  perfectly  symmetrical 
in  arrangement.  The  two  on  one  side  may  be  in 
normal  position,  while  one  or  both  of  the  glandules  on 
the  other  side  may  be  considerably  above  or  below 
or  laterally  removed  from  their  normal  position. 

When  the  neck  organs  are  removed  as  at  autopsy 
and  observed  from  the  posterior  (oesophageal)  side, 
the  superior  parathyroids  are  seen  in  the  loose  fatty 
tissue  along  the  posterior  edge  of  the  thyroid  lobes. 
By  careful  dissection  the  superior  parathyroids  can 
be  exposed  lying  on  the  posterior  wall  of  the  thyroid 
near  the  oesophagus  at  the  place  where  the  artery 
divides.  The  inferior  parathyroids  lie  near  the  pos- 
terior edge  of  the  thyroid  in  the  loose  tissue  that  fills 
the  space  below  the  rounded  lower  pole  of  the  thy- 
roid, ventral  to  the  inferior  thyroid  artery  and  the 
recurrent  laryngeal  nerve. 

Size. — The  average  size  of  the  parathyroid  glands 
is  six  to  seven  millimeters  long,  by   three    to  four 


PLATE  XXXIV 


P.  T.        PARATHYROID     GLANDULES     IN     NORMAL    SITUATION     ON    POSTERIOR 
SURFACE  OF  THYROID   GLAND. 


ANATOMY  211 

millimeters  wide,  by  one  and  a  half  to  five  milli- 
meters thick.  Their  most  constant  dimension  is  their 
thickness.  Sandstroem  found  one  gland  measuring  fif- 
teen millimeters  in  longest  diameter.  Berkeley  gives 
the  average  measurement  as  6x4x2  m.  m.  MacCal- 
lum's  figures  are  about  the  same,  six  to  eight  milli- 
meters long  by  three  millimeters  wide  by  one  to  two 
millimeters  thick.  Berkeley  gives  the  maximum 
total  weight  of  four  glands  out  of  125  autopsies  as 
.3763  grams. 

Shape. — The  parathyroid  glandules  usually  appear 
as  somewhat  flattened,  oval  or  spherical  disk-like 
bodies.  They  may  have  a  flattened  pyriform  out- 
line. Sometimes  they  are  bean  or  kidney  shaped, 
resembling  a  small  lymph  node,  but  are  usually  more 
flattened.  At  times  they  may  be  nearly  square  or 
rectangular.  The  bodies  have  been  compared  with 
a  hemp  seed  or  a  grain  of  maize. 

Color. — In  color  the  parathyroids  vary  from  pale 
grayish  white,  to  dark  reddish  brown.  They  prac- 
tically always  show  a  shade  of  yellow,  due  to  their 
fat  content  which  is  apt  to  be  more  pronounced  in 
older  individuals.  Their  color  is  never  exactly  the 
same  as  the  adjacent  thyroid  tissue  or  lymph  nodules. 
They  are  less  transparent  than  the  lymph  nodes,  less 
elastic  than  thyroid  tissue,  and  not  so  flabby  as  small 
fat  tabs  which  may  be  found  in  this  region.  The  sur- 
face of  the  glandules  is  smooth  and  shining,  and  a 
delicate  venous  tracery  is  to  be  seen  under  their 
capsule. 


212  PARATHYROID    GLANDS 

VARIATIONS    IN    THE    NUMBER    OF    PARATHYROID 
GLANDS    IN    MAN. 

While  there  are  normally  four  parathyroid  glands 
in  man  their  small  size,  variation  in  situation,  and 
their  similarity  to  lymph  nodules,  accessory  thy- 
roids and  other  small  bodies  occurring  in  the  neck 
region,  make  their  identification  difficult,  and  the 
average  number  found  in  any  given  series  of  exam- 
inations is  less  than  four  to  each  individual.  The 
average  number  found,  however,  constantly  increases 
with  the  experience  of  the  searcher,  so  that  while 
there  may  actually  be  less  than  four  glands  in  cer- 
tain cases,  the  difficulties  attendant  on  their  deter-  ' 
mination  make  the  diminution  in  this  number  a 
matter  of  not  finding  all  the  glands  in  many  instances 
rather  than  of  the  glands  not  being  present. 

Accessory  parathyroids  may  at  times  be  found. 
Erdheim  found  eight  accessory  glandules  in  one  case 
and  four  in  another;  both  were  cases  of  thyroid 
aplasia.  Schaper  found  six  parathyroids  in  one  case. 
Zuckerkandl  reports  a  case  in  which  there  were 
eight  glandules.  Getzowa  found  displaced  masses 
of  parathyroid  cells  in  seven  cases,  three  of  them  in 
the  thyroid.  Thompson  and  Harris  have  found  five 
glands  in  several  instances;  once  the  extra  gland 
was  imbedded  deeply  in  the  thyroid.  Accessory 
parathyroids  have  been  noted  imbedded  in  remnants 
of  the  thymus,  especially   in  children.     Kursteiner 

The  author,  in  a  number  of  instances,  where  the  most  careful  search  of  fresh  ma- 
terial yielded  only  three  parathyroids,  has  found  a  fourth  glandule  by  putting  the 
neck  organs  in  Pick's  solution  and  subsequently  developing  the  tissue  in  80%  alco- 
hol. Often,  however,  even  this  method  fails  to  disclose  a  missing  glandule  as  a 
gland  is  easily  lost  in  the  material  dissected  away,  or  the  neck  organs  are  removed 
without  taking  tissue  far  enough  below  the  thyroid,  so  that  a  glandule  well  below 
the  thyroid,  which  is  a  not  infrequent  situation,  is  left  behind.  Hardening  the 
neck  organs  in  10%  formalin  solution  especially  if  there  is  much  oedema  and  con- 
gestion of  the  tissue,  also  aids  in  finding  glandules  that  might  be  overlooked  in 
fresh  material 


ANATOMY  213 

calls  attention  to  the  frequency  with  which  remnants 
of  the  thymus  are  found  in  the  loose  tissue  below  the 
lower  pole  of  the  thyroid  frequently  enclosing  a 
parathyroid  fragment. 

Sandstroem  in  fifty  autopsies  found  never  more 
than  two  parathyroids  on  each  side;  five  times  he 
was  only  able  to  find  one  on  each  side  and  twice  he 
found  only  a  single  gland  on  both  sides,  but  he  him- 
self says  that  his  search  was  incomplete. 

Von  Verebely  in  138  cases  found  four  glandules 
108  times.  He  states,  however,  that  in  the  last  100 
of  these  cases  he  found  four  glandules  in  ninety,  which 
is  significant  of  the  increased  number  found  with 
increased  experience  in  their  search. 

Forsyth,  who  groups  his  findings  unilaterally,  ob- 
served in  sixty  cases  one  gland  on  a  side  in  less  than 
half  his  cases,  two  on  a  side  in  one-fourth,  several 
times  three,  in  two  instances  four  and  five,  and  once 
six  parathyroids  on  a  single  side. 

Welsh,  who  made  a  most  exhaustive  anatomical 
and  histological  study  of  these  glands,  found  in  nearly 
all  cases  in  man  two  on  a  side,  and  he  states  that 
when  fewer  are  found,  either  the  glands  have  es- 
caped observation  or  else  there  is  a  more  or  less  inti- 
mate connection  between  two  of  the  glands  so  that 
they  appear  as  one  mass. 

Schreiber,  in  twenty-five  cases,  found  usually  two  on 
a  side,  in  four  cases  only  one  on  a  side  was  found,  in 
two  cases  there  was  one  on  the  right  and  three  on  the 
left  side.    He  did  not  find  more  than  four  in  any  case. 

Benjamins  found  the  internal  parathyroids  so 
rarely  that  he  questioned  if  their  presence  was  not 
due  to  an  abnormality  of  development. 


214  PARATHYROID    GLANDS 

Peterson,  who  studied  100  cases,  does  not  give  his 
exact  findings,  but  says  that  his  results  confirmed 
the  findings  of  earlier  authors.  He  did  not  fail  to 
find  the  parathyroids  in  any  case.     The  external 


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Fig.   62.     Normal  parathyroid  glandule,   low    magnification.      A 
portion  of  the  thyroid  gland  is  shown  at  the  top  of  the  section. 


glandules  he  found  most  constantly  present.  In 
some  cases  he  found  three  glandules  on  one  side  and 
one  on  the  other. 

MacCallum,  in  sixty -four  cases,  found  four  parathy- 
roids thirty-six  times,  three  ten  times,  two  fifteen 


ANATOMY  215 

times,  and  three  times  only  one  glandule.  MacCal- 
lum  says:  "The  number  found  is  directly  propor- 
tional to  the  patience  and  persistence  with  which 
they  are  searched  for."  He  calls  attention,  more- 
over, to  the  especial  difficulty  in  recognizing  these 
glands  in  the  obese  and  in  atrophic  conditions. 

Rogers  and  Ferguson  examined  forty-six  adults 
and  eight  infants  for  parathyroid  glandules.  In 
twelve  cases  no  parathyroids  were  found ;  in  twenty, 
two  were  found;  in  four,  three:  in  three,  there  were 
four  glandules.  The  findings  in  these  cases  are  much 
below  the  average  although  the  investigation  seemed 
to  be  attended  with  much  care. 

Berkeley  tabulates  the  details  of  forty  autopsies 
in  which  his  average  finding  was  about  two  and  a 
half  glands  per  case.  In  one  instance  he  found  six 
glandules.  This  author  emphasizes  the  necessity 
of  experience  in  searching  for  these  glands.  In  his 
first  twenty-five  autopsies  no  glands  at  all  could  be 
found  in  about  four  cases.  In  his  second  twenty- 
five  he  failed  only  once  or  twice  to  find  glandules. 
In  the  last  fifty  cases  he  never  failed. 

Thompson  found  four  glandules  in  thirty-three 
out  of  forty  cases.  Three  of  these  cases  presented 
also  accessory  glandules  (five  instead  of  four  in  each 
instance.)  In  four  of  the  forty  cases  only  three 
glandules  were  found;  in  one  instance  one  of  the 
superior  glandules  was  missing,  in  the  other  cases 
it  was  one  of  the  inferior  glandules  that  was  not 
found.  In  two  cases,  only  the  two  superior  para- 
thyroids were  found;  the  inferior  glandules  were 
missing.  In  one  case  no  parathyroids  were  found. 
In  nearly   all   the   cases  where  the  author  did  not 


216  PARATHYROID    GLANDS 

find  four  parathyroids  there  was  some  pathologic 
condition  present  that  made  the  search  difficult. 
Two  cases  were  subsequent  to  carcinoma  operations ; 
one  showed  extensive  tuberculous  cervical  lymph- 
noditis,  and  in  others  the  neck  organs  were  cedema- 
tous  and  congested. 

Thompson  and  Harris  found  four  parathyroids  in 
ninety  per  cent  of  all  cases,  where  careful  search  was 
made  for  the  same. 

THE    PARATHYROID    GLANDULES  *IN    CHILDREN. 

Thompson  has  found  that  the  situation,  general 
appearance,  and  microscopic  structure  of  the  para- 
thyroid glandules  of  the  infant  does  not  differ  essen- 
tially from  that  of  the  adult.  The  glandules  are 
much  smaller  in  the  infant  than  in  the  adult.  They 
average  about  two  to  five  millimeters  in  diameter 
normally  in  the  infant,  while  in  the  adult  they  aver- 
age about  eight  millimeters  in  longest  diameter. 
They  are  more  difficult  to  find  in  the  infant  than  in 
the  adult,  not  only  on  account  of  their  small  size, 
but  owing  to  their  resemblance  to  certain  lenticular 
bits  of  tissue  which  extend  upward  along  the  pos- 
terior border  of  the  thyroid  on  both  sides  of  the 
oesophagus.  This  tissue  is  continuous  with  the  in- 
terscapular gland  of  Hatai,  and  at  a  later  period  of 
infant  life  is  not  to  be  distinguished  microscopically 
from  fat.  In  marantic  infants,  in  whom  there  is  no 
fat,  this  tissue  persists,  and  the  tiny  nodules  are  ex- 
tremely difficult  to  distinguish  in  size,  color,  and  sit- 
uation from  the  parathyroids.  By  preserving  the 
neck  organs  entire  in  Pick's  solution  the  author  was 


ANATOMY  217 

able  to  get  a  color  differentiation  that  distinguished 
this  tissue  from  the  glandules.  Another  source  of 
difficulty  is  in  distinguishing  the  parathyroids,  es- 
pecially the  lower,  from  remnants  of  the  thymus  gland 
which  are  much  more  frequently  found  in  the  infant 
than  in  the  adult.  ■  This  in  many  instances  can  only 
be  done  microscopically.  Several  times  Thompson 
.  found  what  microscopically  appeared  to  be  parathy- 
roids, to  be,  microscopically,  parathyroid  incorpor- 
ated in  a  remnant  of  thymus.  This  finding  is  ex- 
plained by  the  close  embryological  relationship  of 
the  two  structures,  and  Verebely  has  noted  the  same 
thing  in  the  adult.  The  number  of  glandules  found 
were,  owing  to  these  difficulties,  less  than  in  the 
adult.  In  twelve  cases  of  marasmus  the  author 
found  four  glandules  in  six  cases ;  three  were  found  in 
five  cases;  in  one  case  only  two  were  found.  In 
twelve  routine  cases  in  infants  four  glandules  were 
found  in  eight;  three  were  found  in  one  case;  two 
were  found  in  two  cases,  and  only  one  glandule  in 
one  instance. 

BLOOD     SUPPLY. 

The  parathyroid  glands  are  supplied  by  the  para- 
thyroid artery  which  is  a  branch  of  the  inferior  thy- 
roid artery.  Vascular  connections  are  also  found 
between  the  capsule  of  the  thyroid  and  the  para- 
thyroid glands.  Evans  states  that  complete  injec- 
tions have  shown  only  a  scant  blood  supply  to  the 
capsule,  consisting  only  of  a  few  minute  capillaries. 
These  capsular  vessels  have  been  brought  out  with 
considerable  distinctness  by  Thompson  and  Leighton 
after  ligation  of  the  parathyroid  artery  in  dogs. 


218  PARATHYROID    GLANDS 

While  Welsh,  Halsted  and  Evans,  Ginsburg,  and 
Geis,  describe  the  parathyroid  artery  as  a  branch  of 
the  inferior  thyroid,  Pool  has  described  the  para- 
thyroid artery  as  springing  from  the  superior  thy- 
roid artery.  It  is  possible  that  the  superior  thyroid 
artery  may  give  off  a  parathyroid  branch  in  the  rare 
cases  in  which  the  bodies  lie  above  and  behind  the 
upper  pole  of  the  thyroid  gland.  The  parathyroid 
artery,  according  to  Ginsburg,  is  about  a  centimeter 
long.  Evans  finds  variations  in  length  from  four 
or  five  millimeters  to  two  or  three  centimeters. 
Evans  also  describes  a  prominent  anastomosing  chan- 
nel between  the  inferior  and  superior  thyroid  vessels 
running  along  the  posterior  margin  of  the  lateral 
thyroid  lobe  in  eight  out  of  twenty  cases.  In  these 
the  superior  parathyroid  artery  is  a  short  branch 
from  this  channel.  The  parathyroid  artery  enters 
the  gland  at  the  hilum,  and  gives  off  branches  which 
spread  toward  the  periphery  from  which  numerous 
capillaries  arise. 

Ginsburg  calls  attention  to  the  existence  of  a  sec- 
ondary blood  supply  to  the  parathyroid  glands  by 
anastomotic  channels  from  the  opposite  side,  so  that 
even  though  a  ligature  be  applied  to  the  superior 
and  inferior  thyroid  arteries  outside  the  capsule,  the 
parathyroid  glands  may  receive  a  blood  supply  from 
the  opposite  side. 

The  veins  of  the  parathyroid  glands  are  derived 
from  the  inferior  thyroid  vein  either  directly  or  by 
the  intermediary  of  the  veins  which  cover  the  surface 
of  the  thyroid  glands. 

Halsted  has  called  attention  to  the  danger  of 
sacrificing  the  parathyroid  glands  in  the  control  of 


ANATOMY  219 

haemorrhage  during  goitre  operations.  He  recom- 
mends therefore  that  the  thyroid  vessels  be  divided 
as  far  from  the  gland  as  possible  so  as  not  to  cut  off 
the  blood  supply  to  the  parathyroids.  This  opera- 
tion of  "ultra  ligation"  is  done  by  drawing  forward 
the  superior  pole  of  the  thyroid  gland  and  putting 


■■**-%> 


Fig.  63.  Ligation  of  the  parathyroid  artery  in  the  dog,  showing 
that  no  change  takes  place  in  the  glandule  following  such  procedure. 
A  moderate  exudation  of  leucocytes  is  seen  between  the  ligature  and 
the  parathyroid. 

the  superior  thyroid  vessels  on  the  stretch.     From 
above  downwards  and  from  before  backwards  the 
vessels  are  then  divided  at  their  point  of  entrance 
into  the  gland  as  far  peripherally  as  possible. 
Thompson,  Leighton  and  Swarts  have  shown  that 


220  PARATHYROID    GLANDS 

in  the  dog  the  parathyroids  possess  sufficient  collat- 
eral blood  supply  so  that  the  ligation  of  their  main 
vessel  is  of  no  importance.  Dogs  in  which  the  para- 
thyroid artery  to  one  glandule  was  ligated  and  the  other 
three  glandules  were  excised  showed  no  symptoms 
following  the  operation.  If  at  a  second  operation, 
however,  the  ligated  glandule  was  excised  the  dog 
died  in  tetany.  This  showed  that  the  ligated  glan- 
dule was  functionally  sufficient  to  maintain  the  life 
of  the  animal.  Microscopic  examination  of  ligated 
glandules  at  intervals  of  twenty-four  hours  to  several 
months  showed  them  to  be  morphologically  intact. 

PARATHYROID     GLANDULES     IN     MAMMALS     AND 
BIRDS. 

On  account  of  the  experimental  work  that  has 
been  done  on  the  parathyroid  glands  their  anatomy 
has  been  worked  out  with  much  care  in  a  wide  va- 
riety of  animals.  While  in  general  the  situation  and 
number  of  these  glands  is  the  same  in  animals  as 
in  man,  there  are  certain  variations  that  may  be 
briefly  reviewed. 

Cat. — In  the  cat  the  thyroid  consists  of  two  separ- 
ate lobes  not  connected  by  an  isthmus.  The  para- 
thyroids are  four  in  number,  two  on  each  side,  the 
external  usually  free  but  sometimes  imbedded  in 
the  substance  of  the  thyroid  lobe  near  the  internal 
surface.  The  internal  gland  is  smaller  than  the  ex- 
ternal and  is  imbedded  in  the  thyroid  lobe.  Kohn 
was  the  first  to  accurately  describe  these  glandules 
in  the  cat.  According  to  Harvier  and  Morel,  accessory 
parathyroids  are  frequently  found  in  the  thymus 
of  this  animal. 


ANATOMY 


221 


D0g# — The  glandules  in  the  dog  have  a  similar 
situation  to  those  described  in  the  cat,  but  are  sub- 
ject to  more  variation.  The  external  glandule  is 
situated  superficially  near  the  upper  pole  of  the 
thyroid.  It  is  usually  in  close  connection  with  the 
capsule  of  the  thyroid. 

The  internal  parathyroid  is  ordinarily  under  the 
capsule  of  the  thyroid,  but  superficially  situated  in 
the  upper  half  of  the  internal  aspect  of  the  thyroid. 
It  is  identified  with  more  difficulty  than  the  external 
gland  owing  to  its  smaller  size,  greater  variation  in 
position  and  deeper  situation  than  the  former. 

Gley  noted  fourteen  variations  in  the  situation 
of  the  glandules  in  thirty-three  dogs,  and  Alquier 
found  the  classic  situation  of  the  bodies  only  nine 
times  in  fifteen  dogs.  MacCallum  calls  attention  to 
the  fact  that  accessory  parathyroids  may  occur 
deeply  imbedded  in  the  thyroid.  Thompson  and 
Leighton  noted  the  frequent  appearance  of  accessory 
parathyroid  glandules  in  this  animal;  eight  glands 
were  found  in  one  animal.  Moussu  speaks  of  supple- 
mentary parathyroid  tissue  about  the  trachea  and 
in  connection  with  the  branches  of  the  thyroid  ar- 
tery. Pianca  has  noted  these  aberrant  glandules 
in  this  animal.  Alquier  has  also  found  accessory 
parathyroids  in  the  dog,  but  these  always  in  connec- 
tion with  the  thyroid  gland. 

The  size  of  the  parathyroids  also  varies  greatly  in 
the  dog.  They  may  be  so  small  as  to  be  scarcely 
visible  to  the  naked  eye,  or  they  may  be  found  as 
large  as  five  millimeters  in  diameter. 

The  irregularity  of  the  glandules  in  this  animal, 
and  the  frequent  finding  of  accessory  parathyroids 


222  PARATHYROID    GLANDS 

should  be  borne  in  mind  in  considering  the  results 
of  experimental  work  in  the  dog. 

Monkey. — In  the  monkey  the  thyroid  lobes  may 
or  may  not  be  connected  by  an  isthmus.  The  para- 
thyroids are  four  in  number,  two  on  each  side,  an 
outer  larger,  and  a  smaller  inner  body.  According 
to  Vincent  and  Jolly  both  glandules  are  frequently 
imbedded  in  the  substance  of  the  thyroid  so  that 
simple  parathyroidectomy  is  extremely  difficult  in 
these  animals. 

Guinea  Pig. — Comparatively  little  attention  has 
been  paid  to  the  parathyroids  of  the  guinea  pig. 
Vincent  and  Jolly  state  that  the  number  and  position 
of  these  bodies  is  extremely  variable  in  this  animal. 
As  a  general  rule  two  of  the  glandules  are  more  or 
less  deeply  imbedded  in  the  thyroid,  while  the  other 
two  are  distinct  from  the  thyroid  substance  and 
separated  from  it  by  a  variable  interval.  The  above 
mentioned  authors  have  found  as  many  as  six  glan- 
dules in  one  animal. 

Rabbit.— The  superior  parathyroids  are  imbedded 
in  the  thyroid  lobes.  The  inferior  parathyroids  are 
distinct  from  the  thyroid  lobes,  and  sometimes  con- 
siderably removed  from  them.  The  inferior  bodies 
are  considerably  larger  than  the  superior  in  this 
animal. 

Rat. — This  animal  possesses  only  two  parathy- 
roid glands.  They  are  situated  within  the  thyroid 
lobes  near  the  upper  pole. 

Horse. — Litty  found  in  the  horse  a  parathyroid 
gland  on  each  side,  embedded  in  the  thyroid  lobe, 
yellowish  red,  round  or  oval,  measuring  about  one 
centimeter  in  diameter.     Estes  has  described  in  the 


ANATOMY 


223 


horse  both  an  external  and  an  internal  parathyroid. 
The  former  is  found  easily  and  is  from  pea  to  hazel 
nut  size.  It  has  a  peculiar  lobulated  appearance. 
It  is  most  often  found  near  the  superior  pole  of  the 
thyroid,  usually  in  the  peri-thyroid  areolar  tissue. 
Its  position  varies  with  the  variations  of  the  thyro- 
laryngeal  artery.  The  internal  parathyroid  was 
found  by  Estes  only  by  making  histologic  sections  of 
the  thyroid  gland  after  hardening  the  same.  Even 
by  this  method  the  internal  gland  was  found  in  only 
about  half  the  cases  and  its  distribution  was  very 
irreeular.  It  could  be  easily  confused  in  gross  with 
small  adenomatous  growths,  which  are  not  uncom- 
mon in  the  thyroid  of  the  horse. 

Sheep  and  Goat.  —  MacCallum,  Thomson  and 
Murphy  have  found  a  very  irregular  distribution  of 
the  parathyroid  tissue  in  these  animals.  Four  para- 
thyroids were  found  quite  regularly  in  the  thymus 
and  thyroid  but  this  does  not  include  all  the  parathy- 
roid tissue  in  these  animals.  Two  glands  are  to  be 
found  imbedded  or  partly  imbedded  in  the  thymus, 
one  on  each  side,  at  the  level  of  the  thyroid  cartilage 
and  just  in  front  of  the  carotid  artery  and  vagus 
nerve,  and  may  easily  be  distinguished  with  the 
naked  eye.  These  glands  measure  from  about  three 
to  five  millimeters  in  diameter.  The  remaining 
parathyroids  are  imbedded  in  the  thyroid  lobes. 
They  cannot  be  easily  seen  in  the  living  animal. 
When  the  thyroid  is  removed  and  hardened,  however, 
they  stand  out  plainly  from  the  surrounding  thyroid 
tissue  with  which  they  come  into  very  intimate  re- 
lation through  lack  of  capsule. 


224  PARATHYROID    GLANDS 

Ox. — In  the  ox  the  external  parathyroids  lie,  one 
on  each  side,  just  under  cover  of  the  free  dorsal  bor- 
ders of  the  lateral  lobes  of  the  thyroid  opposite  about 
the  lower  level  of  the  isthmus.  They  occupy  the 
stratum  of  fat  which  separates  the  thyroid  lobe 
ventrally  from  the  pharynx  and  oesophagus  dorsally. 
They  may  be  blended  with  islets  of  thymus  tissue. 
The  internal  parathyroids  are  incorporated  within 
the  thyroid  gland. 

Forsyth  has  made  a  very  complete  study  of  the 
parathyroid  glands  in  mammals  and  birds.  He  ex- 
amined forty-two  species  of  the  former  and  thirty- 
five  of  the  latter.  This  detailed  search  has  led  the 
author  to  conclude  that  the  parathyroids  vary  widely 
in  number  in  different  species  and  even  in  different 
members  of  the  same  species.  "An  instance  of  this 
is  afforded  by  three  specimens  of  the  Green  Monkey 
in  which  the  parathyroids  numbered  one,  one,  and 
eight  respectively.  Further,  the  existence  of  para- 
thyroid tissue  in  the  thyroid,  not  isolated  by  connec- 
tive tissue,  has  been  found  to  be  of  much  commoner 
occurrence  than  was  supposed.  Even  in  the  same 
species  the  parathyroids  were  found  subject  to  con- 
siderable variations  in  number  and  in  position. 
"Further,  parathyroid  tissue  is  commonly  present 
in  the  thyroid,  and  intermediate  types  are  readily 
found  both  in  the  thyroid  and  in  accessory  glands, 
with  the  result  that  the  identity  of  some  bodies  has 
often  presented  difficulty." 

"Isolated  glands  possessing  a  parathyroid  structure 
were  found  in  most,  but  not  in  all,  the  members  of 
the  series.  When  present  their  total  number  was 
two,  three,  or  four;  but  these  numbers  were  exceeded 


ANATOMY  225 

in  certain  specimens.  A  two-spotted  paradoxure 
{Naudinia  binotata)  and  a  fossa  (Crypto  pro  eta  ferox) 
each  had  six;  a  Green  Monkey  (Cercopithecus  calli- 
trichus)  eight,  and  a  collared  Fruit  Bat  (Cynonyc- 
teris  collar  is),  ten." 

'  'The  parathyroids  can  scarcely  be  said  to  possess 
any  definite  anatomical  relations  in  these  animals, 
so  widely  do  their  positions  vary.  The  commonest 
site  of  occurrence  was  on  the  convex  lateral  surface  of 
the  thyroid ;  but  they  were  also  found  on  the  tracheal 
surface,  or  sunk  in  the  thyroid  either  deeply  or  just 
beneath  the  capsule  or  in  the  immediate  neighbor- 
hood of  the  thyroid,  either  dorsal  anterior,  posterior 
or  external  to  it,  or  some  distance  remote,  either 
isolated  or  in  association  with  accessory  thyroids  or 
lymphatic  glands.  They  present  no  naked-eye  fea- 
ture by  which  their  identity  can  be  established;  and 
over  and  over  again  in  this  series  they  have  been 
found  unexpectedly  on  microscopical  section.  Fre- 
quently glands  too  small  for  macroscopic  identifica- 
tion have  been  found  attached  to  the  capsule  of  the 
thyroid." 

Birds. — The  thyroid  and  parathyroids  of  birds, 
as  examined  by  Forsyth,  agree  generally  with  those 
structures  in  mammals,  but  they  also  present  certain 
points  of  contrast."  As  with  mammals,  so  with 
birds,  it  has  sometimes  been  difficult  to  decide 
whether  a  particular  gland  was  to  be  regarded  as  a 
thyroid  or  parathyroid.  Each  of  these  in  its  typical 
appearance  is  of  course  readily  identified,  but  the 
two  structures  are  so  often  intermixed  that  it  is 
not  always  easy  to  settle  which  name  to  give  to  the 
whole.     A    few   examples   will    illustrate   this   diffi- 


226  PARATHYROID   GLANDS 

culty.  The  anatomical  thyroid  of  the  Californian 
Quail  was  found  to  be  wholly  parathyroid  in  nature. 
In  the  Barn  Owl  only  the  cortex  of  the  thyroid 
possessed  thyroidal  structure ;  the  deeper  parts  were 
typically  parathyroidal.  In  the  Gray  Parrot,  the 
Oyster-Catcher,  and  other  birds  the  anatomical 
parathyroid  was  directly  continuous  with  the  thy- 
roid, no  connective-tissue  septum  being  interposed 
so  that  the  whole  formed  a  single  gland." 

In  the  majority  of  cases  the  number  of  parathyroids 
in  birds  was  found  to  be  limited  to  one  on  each 
side,  lying  in  contact  with  the  thyroid  at  or  near  the 
posterior  pole.  "In  a  few  specimens  the  parathy- 
roid is  bilobed,  while  occasionally  two  separate  para- 
thyroids occur.  When  this  last  condition  holds  it 
is  frequently  found  that  the  glands  are  some  little 
distance  remote  from  the  thyroid.  Most  parathy- 
roids are  oval  or  spherical  in  shape,  and  their  color 
is  white  or  yellow  without  any  translucency." 

Among  the  papers  that  have  appeared  on  the  com- 
parative anatomy  of  the  parathyroids  may  be  men- 
tioned that  of  Pepere,  who  includes  in  his  very  com- 
plete anatomical  study  of  the  parathyroid  glands, 
a  description  of  these  bodies  in  a  number  of  animals 
as  well  as  a  study  of  variations  in  man  from  the  foetus 
to  old  age. 

T^ie  nerve  supply  of  the  parathyroid  glandules 
has  been  studied  by  Sacerdoti,  who  states  that  they 
are  furnished  by  nerves  of  the  thyroid.  According 
to  Anderson  the  nerves  terminate  within  the  in- 
terior of  the  epithelium  of  the  glandule. 


CHAPTER  XIV. 


EMBRYOLOGY  AND  HISTOLOGY. 


When  one  studies  the  development  of  the  para- 
thyroids, and  observes  their  changing  relations  to 
thyroid  and  thymus  in  its  course,  anomalies  in  the 
ultimate  situation  of  these  bodies  are  readily  ac- 
counted for. 

The  thyroid  gland  arises  from  a  median  body  at 
the  root  of  the  tongue,  and  two  lateral  bodies  which 
begin  as  small  buds  from  each  side  of  the  posterior 
wall  of  the  fourth  branchial  cleft. 

The  thymus  gland  arises  from  two  epithelial 
evaginations  of  the  third  branchial  cleft  which  grow 
downward  and  meet  to  form  the  two  lobes  of  this 
body. 

The  parathyroids  arise  as  two  separate  pairs;  one 
from  the  fourth  branchial  cleft,  the  other  from  the 
third  branchial  cleft.  The  former  pair  come  to  lie 
on  the  dorsal  surface  of  the  lateral  portion  of  the 
thyroid  and  form  the  superior  bodies.  The  other 
pair  pass  further  backwards  and  come  to  rest  behind 
the  lower  border  of  the  thyroid,  forming  the  inferior 
bodies.  The  name  "inner"  and  "outer"  bodies  was 
given  these  glandules  by  Kohn  because  of  the  fact 


228  PARATHYROID    GLANDS 

that  in  certain  animals  the  parathyroids  derived 
from  the  fourth  branchial  cleft  were  found  within 
the  thyroid  lobe  while  those  derived  from  the  third 
groove  were  situated  outside  the  thyroid. 

Steida,  as  early  as  1881,  discovered  in  a  pig  em- 
bryo, in  addition  to  the  thymus,  thyroid,  and  caro- 
tid gland,  four  other  epithelial  anlage,  which 
Schreiber  later  described  as  the  parathyroids.  Among 
other  earlier  workers  on  the  embryology  of  these 
bodies  may  be  mentioned  Prenant,  who  described 
an  origin  for  these  organs  in  the  sheep  from  the 
fourth  branchial  cleft  together  with  the  lateral  thy- 
roid bodies.  Tourneux  and  Verdun  also  described 
the  parathyroids  as  arising  from  the  dorsal  part  of 
the  fourth  branchial  cleft  in  human  embryos.  Simon 
observed  the  bodies  in  rabbit  embryos,  and  Gros- 
chuff  in  the  mole.  Soulie  and  Verdun  differentiated 
in  the  rabbit  the  inner  parathyroids  (arising  from 
the  fourth  branchial  cleft)  and  the  outer  parathy- 
roids (arising  from  the  third  branchial  cleft).  Ben- 
jamins, who  included  with  his  own  work  a  discussion 
of  previous  articles,  definitely  stated  that  in  man  the 
bodies  have  independent  anlage  in  both  the  third 
and  fourth  branchial  clefts. 

For  a  more  complete  abstract  of  the  origin  of 
these  bodies  in  various  species  we  are  indebted  to 
Maurer,  who  first  described  the  parathyroids  in 
amphibians : 

Anura. — In  tadpoles  the  parathyroids  arise  at 
the  time  when  the  outer  gills  form.  They  arise  as 
compact  epithelial  buds  on  the  ventral  end  of  the 
third  and  fourth  branchial  clefts;  the  spaces  also 
form  a  similar  bud  which,  according  to  the  observa- 


EMBRYOLOGY    AND    HISTOLOGY  229 

tions  of  Maurer,  goes  to  form  the  carotid  gland. 
The  last  branchial  cleft  forms  no  parathyroid. 

At  first  these  glands  are  histologically  composed 
of  epithelial  cell  masses,  which  stand  in  relation  with 
the  epithelium  of  the  gill  cleft  by  means  of  an  epi- 
thelial pedicle.  This  pedicle  disappears  and  the 
small  structure  grows  by  increase  of  its  cells  to  form 
an  egg-shaped  body  which  may  be  recognized  by 
spiral,  interwoven  cell  cords.  A  lumen  is  never  found 
in  these  organs.  Their  construction  is  peculiar,  dif- 
fering from  the  thymus,  the  thyroid  and  the  post- 
branchial  body.  These  organs  persist  throughout 
life  and  are  found  even  in  very  old  animals,  (frogs, 
toads,  tree-toads). 

Urodeles. — In  triton  the  parathyroids  are  formed 
during  the  metamorphosis  stage.  They  come  from 
the  epithelium  of  the  closing  third  and  fourth  branch- 
ial clefts.  At  the  same  time  the  carotid  gland  arises 
in  the  neighborhood  of  the  second  cleft.  The  bodies 
lie  here  on  the  lateral  convexity  of  the  aortic  arches, 
or  are  between  these.  Sometimes  two  such  bodies 
are  found  between  the  third  and  fourth  arches  so 
that  three  are  formed  on  one  side.  In  other  cases 
there  is  only  one  such  structure  on  one  side,  so  that 
individual  variation  is  not  uncommonly  met  with. 

Reptilia. — In  the  lizard  the  parathyroids  also 
arise  from  the  third  and  fourth  clefts.  In  serpents 
one  body  has  been  found  in  the  second  cleft.  They 
arise  at  the  same  time  as  the  thymus,  during  the 
closure  of  the  branchial  clefts.  In  the  lizard  the 
bodies  arise  from  the  third  cleft  on  the  ventral  end 
of  the  thymus  and  are  in  connection  with  this  through 
an  epithelial  cord.     The  ventral  pocket  of  this  cleft 


230  PARATHYROID    GLANDS 

suffers  a  complete  atrophy.  The  parathyroid  of 
the  fourth  cleft  is  formed  from  the  wall  of  this  cleft 
which  throws  out  a  lateral  projection  from  the  oesoph- 
agus. The  middle  portion  of  this  projection  thick- 
ens and  forms  the  anlage  of  the  parathyroid.  The 
body  is  loosened  from  the  oesophagus  and  for  a  time 
is  in  connection  with  the  post -branchial  body. 

At  first  this  organ  consists  of  epithelial  cells  which 
form  the  boundary  of  a  lumen,  but  with  increase 
of  epithelial  cells  this  lumen  disappears,  and  at  the 
same  time  connective  tissue  elements  enter,  so  that 
the  body  possesses  a  complex  of  epithelial  cells 
which  are  separated  from  one  another  by  delicate 
interstitial  connective  tissue.  In  this  condition  the 
parathyroid  of  the  lizard  remains  throughout  life. 
It  never  contains  a  lumen  and  colloid  substance  is 
never  secreted,  so  that  the  structure  cannot  be  con- 
founded with  that  of  the  thyroid. 

Aves. — In  birds  the  parathyroid  glands  are  pres- 
ent in  varying  number.  They  are  formed  by  the 
third  and  fourth  .gill  cleft  and  lie  ventrally  to  the 
thymus.  According  to  Verdun,  in  the  chick  and  the 
duck,  a  third  body  is  formed  in  connection  with  the 
post -branchial  body  which  is  possibly  a  derivative  of 
the  fifth  branchial  cleft.  Verdun  further  concludes 
that  the  first  two  are  often  in  connection  with  the 
thyroid  and  that  the  derivative  of  the  fourth  cleft 
is  frequently  attached  to  the  post-branchial  body. 

In  mammalia,  as  we  have  already  noted,  these 
structures  arise  from  the  third  and  fourth  branchial 
clefts  and  differ  in  their  relation  to  thymus  and  thy- 
roid from  the  parathyroids  of  the  lower  vertebrates. 


EMBRYOLOGY    AND    HISTOLOGY  231 

At  first  the  parathyroids  of  the  third  cleft  are  in 
direct  relationship  with  the  thymus;  the  two  being 
separated  from  the  oesophagus  at  the  same  time. 
It  is  only  later  that  the  parathyroid  of  the  third 
cleft  separates  itself  from  the  thymus,  and  indeed, 
we  see  that  at  times  a  parathyroid  becomes  imbedded 
in  the  thymus  lobe. 

The  relations  of  the  parathyroids  of  the  fourth 
cleft  are  even  more  complicated.  The  primary  con- 
nection here  is  thymus,  parathyroid  and  post -bran- 
chial bodies,  and  through  this  latter  connection 
the  parathyroids  acquire  a  connection  with  the  thy- 
roid lobe. 

HISTOLOGY. 

Kohn  was  the  first  to  establish  the  independence 
of  the  parathyroid  glands  by  his  ground  breaking 
histologic  and  genetic  study  of  these  organs.  He 
clearly  made  evident  the  distinct  independence  of 
parathyroid  from  thyroid.  Previous  authors  al- 
though they  had  carefully  recorded  the  histologic 
structure  of  these  glands  regarded  them  as  embry- 
onic thyroid. 

The  histology  of  the  parathyroid  glandules  has 
been  described  in  detail  by  various  authors,  includ- 
ing Sandstroem,  Kohn,  Welsh,  Erdheim,  Peterson, 
Verebely  and  Getzowa,  and  save  for  minor  differ- 
ences, the  descriptions  are  fairly  uniform.  All 
authors  describe  two  main  types  of  cells  which  may 
be  grouped  as  follows : 

Type  1. — Comparatively  small  cells  (somewhat 
larger  than  those  of  the  thyroid)  with  relatively 
large  nuclei  which  stain  deeply.     The  cell  cytoplasm 


232  PARATHYROID    GLANDS 

is  colored  with  difficulty,  but  the  cell  border  is  dis- 
tinct. These  cells  constitute  the  greater  part  of 
the  gland  tissue  and  are  always  present  in  every 
glandule,  but  may  vary  in  size,  shape,  and  intensity 
of  cytoplasmic  stain,  and  in  size  and  shape  of  the 
nucleus.  These  cells  will  be  referred  to  as  the  "prin- 
cipal" cells. 


Fig.    64.     Normal   parathyroid  glandule,    ordinary   type   of   cell 
arrangement.     A — Groups  of  "functional"  cells. 

Type  2. — Comparatively  large  cells  with  small 
deeply  staining,  nucleus  and  considerable  deeply 
staining,  eosinophilic,  granular  cytoplasm.  These 
cells  have  a  distinct  cell  boundary.  They  are  not 
found  in  every  glandule,  though  they  are  present  in 
almost  all  cases.     They  are  never  so  numerous  as 


EMBRYOLOGY    AND    HISTOLOGY  266 

the  "principal"  cells.  These  cells  will  be  referred  to 
as  the  "functional"  cells. 

The  number  and  arrangement  of  these  cells  is 
subject  to  wide  variation.  They  may  occur  in  masses 
forming  small  islets  scattered  throughout  the  gland 
tissue,  or  may  occur  irregularly  scattered  among  the 
principal  cells,  either  singly  or  in  groups  of  three 
or  four,  without  any  definite  arrangement.  Some- 
times they  form  definite  acini  or  occur  in  continuous 
anastomosing  columns. 

The  principal  cells  are  also  subject  to  a  great  va- 
riety of  arrangement,  giving  different  pictures  in 
different  glandules.  The  cells  may  form  a  uniform 
mass  continuous  in  every  direction,  being  broken 
only  at  infrequent  intervals  by  delicate  strands  of 
connective  tissue  carrying  small  blood  vessels.  The 
cells  in  this  instance  appear  irregularly  polyhedral, 
and  the  cell  walls  are  everywhere  in  direct  contact 
with  each  other. 

The  glandules  may  show  connective  tissue,  with 
blood  vessels,  between  the  masses,  thus  breaking 
them  into  anastomosing  columns,  or  cell  trabecule. 
Here  the  cell  cytoplasm  stains  more  deeply  and  the 
cells  are  apparently  rounder  than  in  the  former  ar- 
rangement. There  may  be  seen  further  subdivision 
of  the  cell  masses  by  fibrillar  stroma  or  capillary 
reticulum,  or  denser  fibrous  stroma  with-  blood  ves- 
sels, so  that  small  islets  of  epithelial  cells  appear 
within  the  stroma  somewhat  akin  to  the  arrange- 
ment in  carcinoma. 

In  parts  of  the  glandules  the  principal  cells  may 
form  definite  acini,  so  that  the  structure  resembles 


234  PARATHYROID    GLANDS 

secreting  gland,  the  center  of  which  usually  contains 
colloid. 

The  glandules  present,  then,  in  general,  a  together- 
hanging  cell  mass  composed  for  the  most  part  of 
small  cells  with  indistinct  cytoplasm  and  deeply 
staining  nucleus,  interrupted  irregularly  by  small  is- 
lets, or  groups  of  two  or  three,  larger  eosinophilic 
cells,  which  may  or  may  not  have  a  characteristic 
arrangement.  These  cell  masses  are  divided  irregu- 
larly by  blood  vessels  into  lobular  or  reticular  cell 
strings,  or  may  be  separated  into  distinct  lobules  by 
connective  tissue  septa.  Both  the  cells  and  the  con- 
nective tissue  may  contain  considerable  fat,  which 
is  believed  by  most  authors  to  arise  in  the  organ  it- 
self without  outside  influence. 

Sandstroem,  who  described  the  glands  with  con- 
siderable accuracy,  grouped  them  histologically  into 
three  main  types:  1.  A  continuous  mass  of  epi- 
thelial cells  penetrated  by  a  considerable  capillary 
network.  2.  A  continuous  cellular  reticulum,  the 
meshes  of  which  are  occupied  by  blood  vessels  and 
connective  tissue.  3.  An  arrangement  of  cells  into 
numerous  small  follicles,  in  some  of  which  are  drops 
of  a  colloid-like  substance. 

Welsh  confirmed  and  added  to  the  work  of  Sand- 
stroem. He  described  four  types:  "1.  The  cells 
form  a  uniform  mass,  their  protoplasm  taking  little 
if  any  stain,  and  there  being  but  slight  degree  of 
vascularity.  2.  The  cell  masses  show  a  tendency 
to  break  up  into  anastomosing  columns,  between 
which  are  capillaries  borne  in  a  fine  connective  tissue 
stroma ;  the  protoplasm  stains  somewhat  more  deeply 
than  before.     3.    The  cells  form  branching:  columns 


EMBRYOLOGY    AND    HISTOLOGY  235 

between  which  lies  a  fine  or  dense  stroma,  bearing 
blood  vessels.  These  cells  are  large  and  faintly 
staining.  4.  The  cells  are  arranged  in  a  single  layer 
around  a  central  lumen  to  form  definite  acini.  These 
cells  are  large,  with  cytoplasm  staining  variously 
and  the  lumen  is  usually  occupied  by  a  small  globular 
mass  of  colloidal  substance."  Welsh  specially  notes 
that  commonly  several  "types"  coexist  in  one  gland. 

Welsh  also  added  a  description  of  what  he  terms 
"oxyphile"  cells.  These  he  mentions  as  occurring 
in  a  very  large  proportion  of  cases,  though  not  in 
all,  and  never  attaining  the  same  abundance  as  the 
above  mentioned  cells,  ("principal"  cells).  They 
have  a  relatively  large  amount  of  cytoplasm,  which 
is  usually  full  of  fine  oxyphile  granules,  and  he  recog- 
nized what  he  considered  differences  between  the 
nuclei  of  the  two  varieties  of  cells ;  those  of  the  oxy- 
phile being  smaller,  more  nearly  circular,  and  with 
their  chromatin  more  dense.  According  to  their 
grouping  he  makes  four  types  of  these  cells  also. 
They  occur  as:  1. — Uniform  masses  forming  islets 
scattered  irregularly  through  the  gland;  2. — Ana- 
stomosing columns;  3. — Cells  either  singly  or  in 
groups  of  twos  and  threes;  4. — Cells  forming  defi- 
nite acini,  the  lumina  of  which  are  occupied  by  colloid 
material — -a  very  exceptional  type. 

Ebner,  Chantemesse  and  Marie,  Benjamins,  Kohn 
and  Kollman  were  among  the  earlier  contributors  to 
the  histology  of  these  glands.  Their  findings  in 
general  agree  with  what  has  been  related. 

Peterson,  who  carefully  studied  the  glands  in  one 
hundred  autopsies,  noted  that  the  structure  of  the 
parathyroids  varied  from  a  compact  cell  mass,  to  a 


236  PARATHYROID    GLANDS 

gland  composed  of  independent  islets  of  cells  separ- 
ated by  connective  tissue  in  considerable  amount. 
He  separates  the  cells  of  the  parathyroid  distinctly 
into  two  main  types.  The  first  type  is  distinguished 
by  its  strong  affinity  for  the  eosin,  and  when  a  con- 
siderable number  of  these  cells  are  massed  together 
the  picture  is  similar  to  that  of  the  adrenal  gland. 
The  cells  of  the  second  cell  type  are  less  characteristic 
than  the  first.  The  cell  bodies  may  run  into  one  anoth- 
er without  sharp  differentiation  and  are  much  smaller 
than  those  of  the  first  type.  The  cytoplasm  may  be 
so  diminished  that  one  sees  only  a  complex  of  strongly 
colored  nuclei.  Between  these  extreme  forms  are 
all  possible  variations.  Peterson  also  notices  that 
rarely  there  may  be  observed  cylindric  cells  with 
basal  nuclei  which  group  themselves  in  tubular 
gland-like  form.  The  appearance  of  a  third  cell 
type,  noted  by  this  author  (large  voluminous  cells) 
may  represent  a  degenerative  change  rather  than 
normal  histology. 

Peterson's  work  shows  that  the  parathyroid  gland 
is  a  secreting  organ  which  presents  certain  (func- 
tioning) cells  which  set  free  a  secretion  product. 
The  parathyroids  possess  no  duct ;  the  carrying  away 
of  the  secretion  is  by  the  blood  stream,  with  which 
the  cells  are  directly  continuous  by  means  of  capil- 
laries as  in  the  adrenal.  A  proof  of  the  entrance  of 
this  secretion  into  the  blood  is  offered  by  Peterson 
in  the  regularity  with  which  the  red  blood  corpus- 
cles show  an  increased  affinity  for  eosin  (similar  to 
the  cytoplasm  of  the  functioning  cells)  in  congested 
organs  where  secretion  is  increased. 


PLATE  XXXV 


P.  T.        PARATHYROID     GLANDULES.        THE     RIGHT     SUPERIOR     GLANDULE     IS 
DOUBLE.      THE  LEET   SUPERIOR  GLANDULE  IS   SITUATED  ABNORMALLY  LOW. 


EMBRYOLOGY    AND    HISTOLOGY  237 

Koenigstein,  who  studied  in  serial  section  200 
glands,  described  a  passing  over  in  successive  series 
of  the  different  types  of  parathyroid  cells.  The 
large,  polygonal,  eosinophilic,  sharply  bounded  type 
may  be  transformed  into  another  distinct  type, 
smaller,  shrunken  and  having  but  little  affinity  for 
the  eosin.  He  considers  the  difference  in  picture 
due  to  different  stages  in  the  function  of  cells  of  the 
same  original  type,  which  after  filling  with  their 
secretion  present  different  forms. 

Von  Verebely  in  reviewing  these  various  cell  types 
suggests  that  it  is  best  to  consider  that  the  parathy- 
roid is  made  up  of  a  single  cell  type  which  changes 
its  form  and  appearance  under  different  conditions 
of  secretion  and  rest.  This  is  in  line  with  the  views 
previously  expressed  by  Koenigstein  and  later  em- 
phasized by  Forsyth  and  by  Thompson. 

Getzowa  describes  four  types  of  cells  which  are 
designated:  1. — Wasserhelle  cells;  2. — Rosarote  cells; 
3. — Oxyphile     cells;     4. — Syncytium-like  cells. 

Forsyth  lays  special  emphasis  on  the  histologic 
variations  of  activity  and  rest.  The  so-called  oxy- 
phile cells  are  those  distended  with  granular  secre- 
tion, and  the  so-called  principal  cells  represent  the 
exhausted  stage;  intermediate  forms  are  common. 
This  author  states  that  the  granular  secretion  of  the 
cells  is  extruded  into  the  surrounding  lymphatic  spaces. 

So  far  we  have  called  attention  to  the  parenchyma 
rather  than  to  the  framework  of  the  parathyroid, 
although  we  have  spoken  of  the  considerable  varia- 
tion in  the  amount  and  distribution  of  the  latter. 
A  most  careful  study  of  the  framework  of  the  para- 
thyroid glands  by  digestion  methods  has  been  made 


238 


PARATHYROID    GLANDS 


by  Flint.  In  the  dog  and  monkey  this  author  states : 
"In  thin  digested  sections  the  framework  appears  as 
irregular  septa  which  do  not  form  a  continuous  net- 
work throughout  the  organ,  but  are  broken  up  into 
smaller  processes  which  support  the  irregular  coiled 
columns  of  cells  of  which  the  organ  is  composed. 
These  septa  carry  the  arteries,  capillaries,  veins,  and 
nerves.     They  are  in  some  places  built  up  of  fasciculi 


Fig.  65.     Normal  infant  parathyroid  (a)  in  connection  with    (6) 
remnant  of  thymus  gland.    (Magnified  575  times). 

of  reticulum  fibrils,  in  others,  of  a  thinner,  looser 
formation  of  anastomosing  and  branching  fibrils. 
When  thick  stained,  digested  sections  from  fifty 
microns  up  are  studied,  these  broken  septa  are  ob- 
viously continuous  in  the  third  dimension  with  other 
processes  that  turn  off  and  occupy  various  planes 
according  to  the  branching  of  the  anastomosing  cell 
columns.     In  sections  stained  by  the  ordinary  meth- 


EMBRYOLOGY    AND    HISTOLOGY  239 

ods,  and  thin  sections  varying  from  three  to  six 
microns  in  thickness,  stained  by  Mallory's  connective 
tissue  stain,  numerous  cells  with  oval  nuclei  are 
found  imbedded  in  the  fibrils.  These  are  the  con- 
nective tissue  corpuscles,  and  do  not  differ  in  this 
position  from  those  found  in  other  parts  of  the  body." 

HISTOLOGY   OF   THE    INFANT    PARATHYROID. 

Microscopically,  certain  differences  between  in- 
fant and  adult  parathyroid  may  be  noted.  The 
most  noticeable  difference  seems  to  be  that  there  is 
only  a  single  type  of  cell  in  the  infant  glandule.  The 
differentiation  into  "principal"  and  "functional" 
cells,  as  described  for  adult  parathyroids,  cannot  be 
made. 

In  the  infant  Thompson  has  found  that,  micro- 
scopically, the  parathyroid  glandules  present  a  fairly 
uniform  picture.  They  consist  of  closely  set  cell 
masses  arranged  in  groups  or  in  strands,  which  are 
separated  by  a  rather  delicate  connective  tissue 
stroma  bearing  blood  vessels.  The  relation  between 
parenchyma  and  stroma  is  more  uniform,  and  there 
is  less  tendency  to  form  varying  types  of  arrange- 
ment than  in  the  adult.  The  cell  masses  consist 
of  cells  a  little  larger  than  those  of  the  thyroid, 
which  vary  in  size  and  shape  and  intensity  of  nuclear 
and  cytoplasmic  staining,  but  which  conform  to  a 
single  type,  the  so-called  principal  cells  of  the  adult 
glandule.  The  cytoplasm  of  these  cells  may  be  in- 
distinct or  lacking,  but  the  cell  membrane  is  usually 
distinct.  Along  the  capsule  and  septa  these  cells 
frequently  assume    a    radial    arrangement,   the   so- 


240  PARATHYROID  GLANDS 

called  "palisade"  formation.  As  previously  noted, 
the  functional  cells  of  the  adult  do  not  appear  in  the 
infant  gland. 

Erdheim  notes  that  the  structure  of  the  parathy- 
roids in  infants  is  more  solid  than  in  adults,  but  after 
the  twentieth  year  the  parenchyma  undergoes  a 
breaking  up  by  the  penetration  of  connective  tissue 
trabecular.  He  finds  the  functional  cells  first  at 
the  tenth  year  of  life.  After  the  fifth  year  fat  cells 
appear  in  the  connective  tissue  of  the  gland.  This 
fat  increases  with  age  till  it  includes  quite  generally 
the  whole  gland. 

Forsyth  says  that  during  the  first  few  months  of 
life  the  parathyroid  glands  show  no  activity,  and  that 
this  inactivity  may  persist  for  some  years,  although 
in  one  case  colloid  secretion  was  found  as  early  as 
the  third  month. 

HISTOLOGY     IN     ANIMALS. 

In  general  the  histology  of  the  parathyroid  glands 
in  animals  bears  a  close  resemblance  to  the  picture 
seen  in  man.  Forsyth,  to  whose  extensive  work  we 
have  already  referred,  finds  that  these  glandules  are 
usually  made  up  of  solid  masses  of  polygonal  cells 
whose  cytoplasm  may  be  pale  and  clear  or  filled 
with  oxyphile  granules,  or  intermediate  between 
these  extremes.  Often  the  cells  may  arrange  them- 
selves around  a  lumen  which  is  filled  with  a  drop  of 
colloid.  In  birds  this  author  found  that  the  glands 
possessed  a  similar  structure,  with  less  attempt  at 
follicular  formation.  The  cytoplasm  of  the  cells 
showed  the  same  variations  in  activity  and  rest  as 


EMBRYOLOGY    AND    HISTOLOGY  241 

has  been  described  in  mammalian  parathyroids. 
On  the  whole,  the  parathyroids  in  birds  are  more 
often  inactive  than  those  in  mammals. 

Alquier  has  carefully  described  the  structure  of 
these  glands  in  the  dog,  and  divides  them  into  three 
types.  The  first  type  (Type  ordinaire) :  the  cells 
are  large  and  possess  a  clear  finely  granular  pro- 
toplasm with  a  large  nucleus.  These  cells  are  ar- 
ranged in  anastamosing  cords  within  a  mesh-like 
network  in  varying  dimensions.  The  second  type 
(Type  compact) :  consists  of  polyhedral  cells  disposed 
without  order.  The  cells  are  voluminous  and  clear. 
The  third  type  (Type  reticule )  :  the  cells  are  smaller 
and  the  intercellular  spaces  are  not  clearly  defined. 

In  the  sheep  and  goat  the  parathyroids  are  practi- 
cally not  to  be  distinguished  from  one  another  his- 
tologically, according  to  MacCallum.  The  glands 
are  very  compact  and  very  vascular.  The  cells  are 
apparently  all  of  one  type  and  are  closely  arranged 
in  anastomosing  strands  and  cords  so  that  the  in- 
tervening capillaries  come  into  direct  contact  with 
all  the  cells.  The  cell  nuclei  are  large  and  round 
and  the  cytoplasm  very  abundant  with  a  somewhat 
granular  structure.  The  perfectly  clear  cells  and 
the  eosinophile  cells  seen  in  the  human  parathyroid 
are  not  to  be  found  here. 

SECRETION  OF  THE  PARATHYROID  GLAND. 

Various  substances  have  been  noted  in  the  para- 
thyroid gland  appearing  either  as  degeneration  prod- 
ucts or  as  gland  secretion.  Among  these  may  be 
mentioned  colloid,   fat  droplets  and   granules,   gly- 


242  PARATHYROID    GLANDS 

cogen,  hyaline,  and  pigment.  These  substances  will 
be  specifically  dealt  with  in  the  chapter  on  patho- 
logic histology. 

It  was  stated  by  Gley  that  the  parathyroids  (of 
the  dog  and  rabbit)  contained  considerably  more 
iodine  than  did  the  thyroid.  Chenu  and  Morel,  on  the 
contrary,  found  only  a  very  small  amount  of  iodine 
in  these  glandules.  The  work  of  these  latter  authors 
is  sustained  by  Estes  and  Cecil  who  state  that  if 
iodine  is  present  at  all  in  the  parathyroid  it  is  in 
such  minute  quantities  as  to  be  of  no  functional 
significance.  Nagel  and  Ross  found  that  ablation 
of  a  parathyroid  did  not  modify  the  iodine  content 
of  the  remaining  glandules. 

Fiori,  who  has  removed  portions  of  the  parathy- 
roid glands  in  animals,  found  that  no  regeneration 
of  parathyroid  tissue  whatever  took  place  following 
injury.  The  removed  epithelial  tissue  was  replaced 
by  connective  tissue  and  a  cicatrix  resulted  as  is 
the  case  with  all  highly  specialized  tissues. 


CHAPTER  XV. 


THE  PATHOLOGIC  HISTOLOGY  OF  THE 
PARATHYROID  GLANDS. 


While  the  greater  part  of  the  work  on  the  para- 
thyroids has  been  along  experimental  lines,  never- 
theless morphological  observations  relating  to  alter- 
ations from  the  described  normal  histology  have  been 
made  by  a  number  of  investigators,  although  per- 
haps it  might  be  truthfully  stated  that  the  negative 
observations  on  these  bodies  have  been  of  more 
value  in  clearing  our  mind  in  regard  to  certain  dis- 
eases than  any  described  pathological  alteration. 

Sandstroem  mentioned  that  cystic  degeneration, 
and  amyloid  infiltration  of  the  vessel  walls  and  cap- 
sule occurs  in  certain  cases.  Muller  called  especial 
attention  to  fatty  change.  Konigstein  studied  es- 
pecially the  secretion  of  the  glandules  from  a  histo- 
logical standpoint,  but  stated  he  could  not  bring 
anatomical  changes  into  correlation  with  clinical 
conditions.  Harnett,  in  a  series  of  routine  autopsies, 
found  no  changes  in  the  parathyroid  glands  that 
could  be  differentiated  from  normal  glands  at  the 
corresponding  period  of  life.  Verebely  in  one  hun- 
dred and  thirty-eight  cases  described  various  lesions 


244  PARATHYROID    GLANDS 

of  the  glandules,  including  two  instances  of  tuber- 
culosis, three  cases  of  cyst,  three  of  hemorrhage,  and 
one  tumor.  Getzowa  called  especial  attention  to 
the  colloid  content,  which  was  found  present  in 
nearly  all  cases  over  ten  years  of  age.  Pepere  noted 
a  number  of  progressive  and  retrogressive  changes, 
including  suppuration.  Guizzetti  described  dense 
mononuclear  cell  infiltration  of  the  parathyroid  in 
two  cases  of  tetanus.  Yanase  found  hemorrhage 
thirty-three  times  in  eighty-nine  children  showing 
tetanoid  conditions.  Kohn  described  hemorrhagic 
cysts.  Peterson,  who  examined  one  hundred  cases, 
noted  the  frequency  with  which  degenerative  changes 
are  found  in  the  glandules  from  cases  over  twenty 
years  old.  Among  these  changes  he  found  atrophy 
of  the  parenchymatous  cells  brought  about  by  fatty 
changes,  cloudy  swelling,  and  cystic  degeneration 
very  frequently.  In  twenty-five  of  his  cases  he 
found  cloudy  swelling;  in  fifteen,  colloid;  in  six, 
cyst  formation;  in  twenty-one,  fatty  infiltration. 
This  author  was  unable  to  correlate  changes  in  the 
gland  with  clinical  conditions.  Gamier  described 
slight  changes  in  severe  infectious  disease. 

Benjamins,  in  twenty  cases  of  goitre,  found  no  pro- 
gressive changes  in  the  glandules  but  a  variety  of 
retrogressive  changes.  In  a  general  study  of  the 
parathyroids  he  found  hydropic  degeneration  twen- 
ty-five times,  pigment,  atrophy,  connective  tissue 
increase,  and  frequent  colloid.  He  described  a 
tumor  of  the  parathyroid  the  size  of  a  child's  head. 

Erdheim  found  glycogen  and  colloid  frequently 
and  observed  mast  cells  in  the  connective  tissue  of 
certain  of  the  glandules.     He  also  noted  the  fre- 


THE    PATHOLOGIC    HISTOLOGY 


245 


quency  of   cysts.     He  found   hemorrhage   in   eight 
cases. 

Thompson  has  called  attention  to  the  condensa- 
tion of  the  cytoplasm  at  the  edge  of  the  cell  in  these 
glands,  due  to  various  degeneration  products  such 
as  fat,  glycogen,  and  colloid.  This  produces  the 
optical   appearance   of   an   intercellular   framework 


Fig.  66.     Sclerotic  type  of  parathyroid  glandule  showing  epithelial 
islets  separated  by  considerable  connective  tissue. 

which  characterizes  many  of  these  glands.  In.  a 
later  paper  by  the  same  author,  degenerative  and 
especially  progressive  changes  were  described  in 
these  glandules  in  cases  of  primary  infantile  atrophy. 
Forsyth,  who  regards  the  cells  of  the  parathyroids 
as  all  of  a  single  type  representing  different  stages 
of  activity  and  rest,  has  described  excess  of  colloid, 


246  PARATHYROID    GLANDS 

connective  tissue  proliferation,  both  general  and 
perivascular,  and  also  speaks  of  instances  (in  ani- 
mals) where  there  is  a  similarity  between  thyroid 
and  parathyroid  structures.  This  author  also  notes 
that  the  cortex  of  the  gland  stains  more  deeply  than 
the  medullary  tissue,  and  that  drops  of  colloid  and 
regular  vesicles  are  met  with  more  frequently  near 
the  surface  than  elsewhere.  The  nearer  the  sur- 
face, the  more  abundant  the  secretion. 

MacCallum,  who  has  worked  extensively  on  these 
glandules,  found  in  certain  of  the  glandules  examined 
following  thyroid  removal  for  exophthalmic  goitre, 
some  increase  in  fibrous  stroma  and  moderate  atrophy 
of  the  cells.  In  general,  however,  the  parathyroid 
tissue  was  abundant  and  normal  in  these  cases.  A 
tumor  of  a  parathyroid,  and  hyperplasia  of  the  glan- 
dules in  gastric  tetany  has  also  been  noted  by  this 
author. 

Tuberculosis  of  the  parathyroid  glands,  occurring 
as  a  part  of  general  miliary  tuberculosis,  has  been 
described  by  Carnot  and  Delion,  Benjamins,  Verebely, 
Eggers  and  Winternitz. 

Amyloid  infiltration  of  the  parathyroids  has  been 
especially  well  described  by  Schilder  who  found  these 
glandules  involved  in  three  cases  of  amyloidosis. 

The  attempt  to  establish  a  symptom  complex  for 
diseases  of  the  parathyroids  has  been  due  to  the  re- 
sults of  physiological  experimentation  rather  than 
to  histological  findings,  and  a  great  range  of  diseases, 
in  which  tetanic  symptoms  are  present,  has  been 
advanced  as  due  primarily  to  deficiency  in  parathy- 
roid secretion.  In  many  of  these  diseases,  how- 
ever, examination  of  the  parathyroids  has  failed  to 


THE    PATHOLOGIC    HISTOLOGY  247 

reveal  constant  morphological  change  when  symp- 
toms were  such  as  to  suggest  severe  or  complete  loss 
of  their  functioning  power. 

The  various  tetanies  for  which  a  parathyroid 
etiology  seems  most  probable  will  be  discussed  in 
a  later  chapter.  At  present  we  will  only  concern 
ourselves  with  such  morphologic  work  as  concerns 
these  conditions,  as  well  as  the  results  of  a  study  of 
these  bodies  in  those  diseases  in  which  a  parathyroid 
etiology  has  been  suggested  but  found  lacking. 

Exophthalmic  Goitre. — The  suggestion  that  ex- 
ophthalmic goitre  might  be  due  to  lesions  of  the  para- 
thyroid glands  suggested  itself  very  soon  after  tetanic 
symptoms  were  noted  following  the  removal  of  these 
bodies.  Moussu  was  probably  the  first  to  formulate 
this  theory.  At  about  the  same  time  papers  ap- 
peared by  Gley  and  by  Edmunds,  the  former  sug- 
gesting alterations  in  the  thyroid  apparatus  involv- 
ing in  the  first  place  the  parathyroids,  and  the  latter 
partial  aparathyroidia  as  an  explanation  of  this 
disease. 

Edmunds  has  also  stated  that  when  the  parathy- 
roids are  removed  in  the  dog  the  thyroid  gland  un- 
dergoes compensating  hypertrophy  with  changes  sim- 
ilar to  those  found  in  exophthalmic  goitre,  namely 
"enlargement  of  the  vesicles  with  alteration  in  shape 
from  round  to  oblong  or  branched;  intracellular 
growth  takes  place,  the  secretory  cells  become  col- 
lumnar  instead  of  cuboidal  and  the  colloid  contents 
of  the  vesicle  tend  to  disappear." 

Humphry,  on  the  basis  of  this  assertion,  describes 
two  cases  of  exophthalmic  goitre  in  which  the  para- 
thyroids (only  two  of  which  were  found  in  each  case) 


248  PARATHYROID    GLANDS 

exhibited  extensive  infiltration  of  fat.  In  another 
case  there  was  some  fat,  and  in  a  fourth  case  (age, 
twenty- two  years),  there  was  no  fatty  infiltration. 
For  comparison  the  author  examined  microscopically 
the  parathyroids  in  eighteen  cases,  not  goitre,  and 
came  to  the  conclusion  that  it  would  be  premature 
to  consider  this  fatty  change  as  a  pathological  fea- 
ture of  Graves'  disease  without  further  observation. 

Haskovec,  on  the  ground  of  his  experimental  in- 
vestigation of  exophthalmic  goitre,  concludes  that, 
while  this  disease  has  its  origin  in  the  thyroid  gland, 
the  parathyroids  should  be  considered  as  participat- 
ing in  the  condition. 

In  general  it  may  be  stated  that  no  characteristic 
histological  changes  are  found  in  the  parathyroid 
glands  in  connection  with  this  disease.  Erdheim 
examined  a  case,  in  which  exophthalmic  goitre  and 
epilepsy  were  combined,  and  found  no  changes  save 
for  the  usually  fatty  infiltration  that  might  be  ex- 
pected in  a  flfty-three-year  old  man.  Benjamins 
also  failed  to  find  changes  in  the  parathyroid  glands 
in  this  condition.  This  author  examined  the  para- 
thyroids from  twenty  cases  of  goitre  of  various  kinds 
including  three  cases  of  exophthalmic  goitre. 

MacCallum,  who  has  examined  the  parathyroids 
from  a  number  of  cases  of  exophthalmic  goitre,  states 
that  there  are  no  constant  lesions  in  these  organs  in 
this  disease. 

On  the  negative  histological  findings,  then,  as 
well  as  on  the  fact  that  the  symptoms  in  parathy- 
roidectomized  animals  are  very  different  from  those 
of  exophthalmic  goitre,  and  considering  that  para- 
thyroid therapy  is  of  no  benefit  in  the  disease,  we 


THE    PATHOLOGIC    HISTOLOGY  249 

can  conclude  that  the  parathyroids  have  little  or 
nothing  to  do  with  this  condition. 

Myxoedema. — It  is  to  be  questioned  if  the  para- 
thyroid glands  play  any  role  whatever  in  the  causa- 
tion of  myxcedema,  which  is  definitely  known  to  be 
due  to  loss  of  the  thyroid  gland.  Occasionally, 
however,  certain  disturbances  in  the  muscles  have 
been  observed  in  the  course  of  this  disease,  as  re- 
ported by  Lundborg,  Schlesinger,  Rosenberg,  and 
others,  wThich  might  suggest  that  the  parathyroids 
were  also  involved. 

Maresch  and  Peucker  found  the  parathyroids  pres- 
ent in  cases  of  congenital  absence  of  the  thyroid. 
Erdheim  found  in  several  cases  where  there  was 
absolute  aplasia  of  the  thyroid,  not  only  the  four 
normal  parathyroids  but  a  number  of  accessory 
glandules,  none  of  which  presented  any  pathological 
alteration. 

Forsyth  has  reported  a  case  of  myxoedema  .  of 
four  years  standing  in  a  woman  aged  fifty-eight, 
which  showed  in  addition  to  the  typical  sclerotic 
changes  in  the  thyroid,  certain  departures  from  the 
normal  structures  of  the  parathyroid  glands.  The 
bodies  showed  a  marked  tendency  to  form  vesicles 
lined  by  a  cubical  epithelium,  with  a  profuse  secre- 
tion of  colloid  which  filled  the  follicles  and  lay  among 
the  masses  of  cells  and  distended  the  lymphatic 
channels.  There  was  also  observed  an  abnormal  in- 
crease in  the  connective  tissue  and  a  thickening  of 
the  arterial  walls  of  these  glandules.  Such  a  change 
as  this  is  too  commonly  observed,  however,  in  para- 
thyroid glands  from  ordinary  cases  of  people  of  this 
age  to  make  Forsyth's  observation   of    any   impor- 


250 


PARATHYROID    GLANDS 


tance.  Both  fibrosis  and  colloid  are  frequently  found 
in  the  parathyroids. 

Brissaud  considers  the  parathyroids  to  be  involved 
in  myxcedematous  idiots,  and  not  involved  in 
myxcedema  frustes. 

Epilepsy. — Owing  to  certain  of  the  symptoms 
that  have  been  observed  in  animals  following  in- 
complete operation  on  the  parathyroids  it  was  early 


Fig.  67.  Parathjrroicl  glandule  of  the  sclerotic  type,  from  a  case  of 
primary  infantile  atrophy,  high  power,  showing  (a)  perivascular  in- 
crease of  connective  tissue,  (b)  crowding  together  of  epithelial  cells 
and  (c)  mast  cells  in  connective  tissue.     (Magnified  575  times.) 


suggested  (Jeandelize,  Vassale,  MacCallum),  that 
epilepsy  might  in  certain  instances  have  a  relation- 
ship to  changes  in  the  parathyroid  gland.  Erd- 
heim,  indeed  found  considerable  increase  of  connec- 
tive tissue  of  all  four  parathyroids  in  a  case  of  epi- 
lepsy in  a  twenty-three-year  old  male,  but  in  another 
case  he  found  the  glands  perfectly  normal.    Schmorl 


THE    PATHOLOGIC    HISTOLOGY  251 

found  hemorrhage  in  the  parathyroids  in  two  cases 
of  epilepsy. 

Claude  and  Schmiergeld  examined  the  parathy- 
roids, as  well  as  the  thyroid  glands,  in  seventeen 
cases  of  epilepsy,  and  found  no  changes  in  the  former 
that  they  were  able  to  construe  as  pathologic  for 
this  condition. 

Paralysis  Agitans.— As  early  as  1885,  Horsley 
from  observations  on  thyroidectomized  apes,  de- 
scribed certain  muscular  tremors  and  stated  that 
the  causation  of  the  constant  tremor  such  as  that 
in  paralysis  agitans  might  find  an  explanation  in  the 
loss  of  the  thyroid  apparatus.  He  did  not  consider 
the  parathyroids  at  that  time,  as  up  to  then  little 
or  no  attention  had  been  paid  to  these  organs,  but 
of  course,  a  considerable  amount  of  parathyroid 
tissue  had  been  removed  in  his  animals.  Despite 
Horsley's  observation  no  attention  was  paid  to  these 
organs  as  far  as  paralysis  agitans  was  concerned 
until  1904,  when  Lundborg's  well  known  paper  on 
the  relation  of  the  parathyroids  to  paralysis  agitans 
appeared.  The  same  hypothesis  was  advanced  by 
Berkeley  independently  although  his  paper  did  not 
appear  until  later. 

Both  these  papers  were  wholly  hypothetical, 
Lundborg  having  no  autopsy  material  on  which  he 
could  prove-  his  assumptions,  and  Berkeley  being 
able  to  secure  but  one  autopsy  in  this  condition. 
In  this  case  he  found  two  parathyroid  glands,  which 
are  described  as  less  than  average  size,  and  as  pre- 
senting sclerosis  and  thickening  of  the  blood  vessels 
in  part,  with  other  parts  of  the  gland  appearing 
normal. 


252  PARATHYROID   GLANDS 

The  hypothetical  part  of  both  these  articles  is  not 
without  interest.  Lundborg  cited  Luzzato,  Dana, 
Mobius,  Frenkel,  Burzio,  Casteloi  and  SchiefTer- 
decker,  all  as  expressing  the  idea  that  the  disease 
is  an  endogenous  toxemia.  He  emphasized  the 
tetanic  symptoms  that  arise  in  animals  after  para- 
thyroidectomy; and  after  a  considerable  discussion 
which  it  is  impossible  to  abstract  completely,  gives  a 
diagram  wherein  the  system  of  thyroid  and  para- 
thyroid hypo  and  hyper  function  is  delineated  in 
terms  of  myxoedema,  morbus  Basedowii,  paralysis 
agitans,  and  paralysis  myasthenia  respectively.  Lund- 
borg's  paper  must  be  read  in  its  entirety  to  appre- 
ciate the  full  force  of  his  argument.  He  concludes 
with  the  statement,  however,  "das  es  aber  noch  fur 
ausserst  hypotetisch  gehalten  werden  muss,  ob  die 
glandulae  parathyroidae  eine  bestimmte  Rolle  in  deren 
Pathologenese  spielen." 

Berkeley  cites  in  support  of  his  theory:  tetanic 
symptoms  observed  in  slowly  dying  parathyroid- 
ectomized  rabbits;  the  endogenous  toxemia  concept 
of  the  disease,  which  seems  to  be  borne  out  in  a 
measure  by  the  fact  that  the  author  considered  that 
the  administration  of  parathyroid  gland  extract  was 
of  therapeutic  value  in  a  majority  of  his  cases; 
and  the  possibility  that,  in  cases  of  concurrent  myxoe- 
dema and  paralysis  agitans  the  parathyroids  may 
have  been  diseased  or  atrophied  through  contiguity 
with  the  diseased  thyroid. 

Alquier  in  a  general  review  of  this  subject  adds  the 
weight  of  his  opinion  to  this  hypothesis  on  the  ground, 
especially,  that  it  seems  more  probable  than  any  of 
the  previously  advanced  theories. 


THE    PATHOLOGIC    HISTOLOGY  253 

Thompson,  however,  failed  to  find  any  constant 
changes  in  the  parathyroid  glands  of  nine  cases  dy- 
ing of  this  disease,  which  were  controlled  by  the 
examination  of  the  glandules  from  forty  autopsies 
not  paralysis  agitans.  In  summing  up  these  nine 
cases  of  paralysis  agitans  it  was  found  that  the  para- 
thyroid glandules,  in  individuals  dying  with  this 
disease,  presented  no  changes  either  in  number, 
size,  position,  or  histologic  structure  that  would 
serve  to  distinguish  them  from  the  parathyroid 
glandules  in  individuals  dying  from  other  diseases. 

In  two  of  the  nine  cases,  only  three  glandules  were 
found  (in  one  other  case  where  only  three  glandules 
were  found  the  technic  was  faulty).  Many  writers 
find  three  glandules  more  often  than  they  find  four, 
in  routine  examination.  In  three  cases  five  glan- 
dules were  found.  The  finding  of  the  minute  ac- 
cessory parathyroids  in  these  cases  more  frequently 
than  in  the  routine  cases  was  undoubtedly  due  to 
the  extra  care  that  was  used  in  searching  for  them  in 
the  paralysis  agitans  material. 

The  average  size  of  the  glandules  was  a  little 
smaller  in  the  cases  of  paralysis  agitans  than  the 
general  average  of  the  routine  cases.  This  could  be 
accounted  for  by  the  fact  that  all  the  paralysis 
agitans  cases  were  over  seventy  years  of  age.  Rou- 
tine cases  over  seventy  years  of  age  show  in  general 
smaller  glandules  than  young  individuals. 

There  was  nothing  to  be  found  microscopically  in 
the  parathyroids  in  the  paralysis  agitans  cases  that 
could  differentiate  them  from  other  parathyroids. 
Five  of  the  cases  can  be  passed  over  without  remark  ; 
they  were  in  every  way  identical  with  the  type  pic- 


254  PARATHYROID    GLANDS 

ture  presented  by  the  majority  of  the  glandules  in 
routine  parathyroid  examination.  Two  of  the  cases 
presented  a  moderate  increase  of  connective  tissue 
stroma.  The  percentage  of  glandules  showing  a 
considerable  connective  tissue  stroma  was  higher  in 
the  routine  cases  than  in  paralysis  agitans.  Eight 
of  the  routine  cases  were  of  this  type.  One  of  the 
paralysis  agitans  cases  showed  a  great  amount  of 
interlobular  fatty  connective  tissue,  so  that  only 
small  islets  of  glandular  tissue  were  seen.  Three 
of  the  routine  cases,  however,  gave  even  greater  con- 
nective tissue  stroma,  with  corresponding  atrophy 
of  the  parenchyma.  Fat  was  found  in  every  glan- 
dule examined,  both  in  the  paralysis  agitans  and  the 
routine  cases.  Some  of  the  paralysis  agitans  cases 
showed  a  great  amount  of  fat.  Many  of  the  routine 
cases  showed  an  equal  amount,  and  some  even  more. 
The  glandule  that  showed  the  most  fat  was  from  a 
case  of  diabetes. 

All  the  cases  of  paralysis  agitans  showed  both 
types  of  cells  (principal  and  functional),-  although 
the  ratio  between  the  two  varied  greatly  in  different 
cases  and  in  different  glandules  from  the  same  case, 
as  they  did  also  in  the  routine  cases.  In  one  case, 
one  of  the  inferior  glandules  exhibited  apparent  in- 
creased activity  of  the  functional  cells.  No  mitotic 
figures  were  seen  in  the  principal  cells,  in  either  the 
paralysis  agitans  or  the  routine  cases. 

Erdheim  also  examined  the  parathyroids  in  three 
cases  of  paralysis  agitans  and  found  no  evidence  of 
hypoplasia.  In  two  of  the  cases  the  glandules  were 
perfectly  normal.  In  the  third  case  one  glandule 
was  greatly  enlarged   and  showed  marked  increase 


PLATE  XXXVI 


/.*- 


P.  T.  SUrERIOE  PARATHYROIDS.  THE  LEFT  IS  ABNORMALLY  HIGH.  THE 
INFERIOR  GLANDULES  (NOT  SHOWN)  ARE  ON  THE  ANTERIOR  SURFACE  OF  THE 
THYROID  LOBES. 


THE    PATHOLOGIC    HISTOLOGY  255 

in  the  functional  cells  while  the  other  three  glan- 
dules were  normal. 

In  conclusion,  then,  it  must  be  stated  that  there 
is  no  morphologic  ground  for  the  assumption  that 
the  parathyroid  glandules  are  insufficient  in  paral- 
ysis agitans.  Whether  or  not  there  is  faulty  secre- 
tion of  these  organs;  whether  they  are  unable  to 
cope  with  a  poison  circulating  in  the  blood  that  their 
cells  or  their  secretion  is  not  able  to  neutralize;  or 
whether  the  specific  relation  between  these  glan- 
dules and  some  other  organ  is  upset,  must  be  deter- 
mined by  experimentation  other  than  morphologic, 
and  offers  a  promising  field  for  investigation.  On 
morphologic  grounds  there  is  every  reason  to  oppose 
the  hypothesis  that  paralysis  agitans  is  a  chronic, 
progressive  hypoparathyroidismus . 

Tetany. — Microscopic  lesions  have  been  described 
in  the  parathyroids  in  various  forms  of  tetany, 
which  will  be  dealt  with  in  more  detail  in  a  later 
chapter.  MacCallum  found  hyperfunction  of  the 
glandules  in  gastric  tetany,  and  Konigstein  also  re- 
ported a  case  in  which  similar  changes  were  found. 

Tetanus. — In  tetanus  Guizzetti  found  infiltration 
of  mononuclear  cells  in  two  cases  in  which  the  dis- 
ease had  lasted  for  four  and  seven  days,  respectively. 
Two  other  cases  were  negative.  Babonneix  and 
Harvier  have  described  changes  in  the  parathyroids 
in  three  cases  of  tetanus,  consisting  especially  in 
hypersecretion  of  colloid.  Thompson  found  no 
changes  in  the  parathyroids  in  five  cases  dying  from 
tetanus  infection  that  could  be  considered  specific. 
Erdheim  found  the  glandules  normal  in  one  case. 


256  PARATHYROID    GLANDS 

In   a   case   of   experimental   tetanus   the    glandules 
were  found  normal  by  Gamier. 

Tetany  of  Children. — Erdheim  (three  cases)  and 
Konigstein  have  found  hemorrhage  in  the  para- 
thyroids in  children  exhibiting  tetanic  symptoms. 
Verebely,  and  also  Thiemich,  have  found  hemor- 
rhages in  cases  where  there  was  no  tetany.  The  most 
convincing  work  in  this  line  has  perhaps  been  done 
by  Yanasse  who  examined  the  parathyroids  in  eighty- 
nine  children  showing  tetanoid  conditions  and  found 
hemorrhage  in  thirty-five  cases.  Degeneration  of 
the  parathyroids  in  a  case  of  tetany  in  course  of  a 
case  of  tuberculous  meningitis  has  been  described 
by  Escherich. 

Eclampsia. — The  greater  amount  of  work  on  this 
condition  has  been  experimental  and  is  given  in  more 
detail  in  a  later  chapter,  but  several  authors  have 
examined  the  parathyroids  histologically  in  this 
condition.  Pepere  found  changes  in  the  glandules  in 
four  cases.  Zanfrognini  found  only  two  glandules 
in  a  case,  but  these  were  both  normal.  Erdheim 
in  four  cases  found  hyperemia,  circumscribed  injury 
once,  hemorrhage  once.  Schmorl  in  five  cases  of 
eclampsia  found  hemorrhage  four  times.  He  con- 
siders that  the  hemorrhage  was  the  result  of  the 
convulsions. 

Rachitis. — Escherich,  under  whom  the  work  of 
Yanasse  previously  cited  was  done,  has  suggested 
congenital  parathyroid  hypoplasia  as  the  etiological 
factor  in  rachitis.  This  assumption  is  based  on  the 
frequent  coincidence  of  tetany  and  beginning  rachitis ' 
as  well  as  on  Erdheim 's  findings  in  the  teeth  of  para- 
thyroidectomized  rats.     At  present  this  hypothesis 


THE    PATHOLOGIC    HISTOLOGY  257 

lacks  morphological  confirmation.  Schmorl  found  no 
changes  in  the  parathyroids  in  four  cases  of  rachitis. 

Osteomalacia. — In  two  autopsies  in  this  disease 
Erdheim  found  hyperplasia  of  the  parathyroids  in 
one  case  and  normal  glandules  in  the  other  case. 
Schmorl  in  four  cases  found  the  glandules  normal 
three  times  and  hyperplasia  in  one  case  of  one  of  the 
upper  glandules. 

Primary  Infantile  Atrophy. — In  this  disease  Thomp- 
son found  constant  changes  in  the  parathyroids, 
practically  all  of  a  progressive  nature,  which  the 
author  considered  the  result  of  this  condition  rather 
than  an  etiological  factor  in  the  same. 

In  the  cases  of  infantile  atrophy  the  changes  that 
are  found  in  the  parathyroids  can  be  quite  sharply 
differentiated  into  two  types,  which  may  be  desig- 
nated as  (a)  degenerative,  and  (b)  sclerotic.  In  the 
first  type  the  glandules  may  be  diminished  in  size 
or  may  be  of  normal  size,  and  are  pale  in  color,  or, 
as  in  one  case  that  showed  intense  congestion,  the 
glandules  were  cherry  red.  Microscopically,  no  in- 
crease of  connective  tissue  is  found,  but  the  epithelial 
cells  show  everywhere  a  marked  degeneration.  They 
are  larger  and  more  irregular  than  normal,  the  nuclei 
are  swollen  and  the  cell  boundaries  are  usually 
thickened,  appearing  as  though  the  protoplasm  had 
condensed  in  part  at  the  cell  periphery,  as  happens 
in  certain  forms  of  reticular  degeneration.  In  places 
there  was  complete  loss  of  cell  structure  with  crowd- 
ing' together  of  the  cytoplasm  into  a  fused  mass,  in 
which  the  nuclei  were  irregularly  arranged.  The 
blood  vessels  may  be  greatly  distended,  but  are 
usually  moderately  injected. 


258 


PARATHYROID    GLANDS 


Fig.  68.  A  and  B.  Sketch  of  the  neck  organs  from  cases  of  primary 
infantile  atrophy,  showing  the  small  size  of  the  parathyroid  glandules; 
compare  with  C'and  D,  which  are  control  cases  of  infants  of  the  same 
age.  (pt)  parathyroids,  (th)  remnants  of  thymus  gland  (in  B  replacing 
the  two  lower  parathyroids  and  surrounding  the  left  upper);  (gl) 
represents  tissue  continuous  with  the  interscapular  gland.  (In) 
lymph  node. 


THE    PATHOLOGIC    HISTOLOGY  259 

The  most  common  finding,  however,  in  these  cases 
of  marasmus  is  a  marked  increase  in  the  connective 
tissue  stroma  of  the  glandules,  which  corresponds 
closely  to  the  sclerosis  (chronic  fibrous  parathyroid- 
itis),  described  in  the  adult.     These  cases  are  called, 
therefore,   the   sclerotic   type.     In   these   cases  the 
glandules  are  smaller  than  normal,  dark  brownish- 
red  in  color,  and  firm.     Microscopically  the  connec- 
tive tissue  stroma  separating  the  cell  masses  is  found 
increased  in  amount  in  varying  degree.     The  epith- 
elial cells  appear  as  irregular  strands  between  the 
thickened  bands  of  connective  tissue.     This  connec- 
tive tissue  increase  is  frequently  noted   about  the 
blood  vessels.     The  connective  tissue  is  loose,  vas- 
cular, and  rich  in  nuclei,  which  have  a  spindle  shape. 
Mast  cells  are  frequently  seen  in  the  connective  tis- 
sue.    In  the  epithelial  islets  between  the  connective 
tissue  strands  the  principal  cells  are  crowded  to- 
gether  so   that   the   typical    sharp-lined    epithelial 
structure  is  lost.     The  cell  membrane  is  usually  not 
seen,  but  masses  consisting  of  closely  set,  irregularly 
arranged   nuclei,    without   definite   cell   boundaries, 
are  apparent.     Groups  of  five  or  six  cells  occasion- 
ally in  the   centres   of  these   islets  preserve  their 
original  structure.     As  tetany  was  never  observed 
in  these  cases  the  findings  are  interesting  as  tending 
to  show  that    extensive    changes   may   take   place 
in     the    parathyroids    without    exhibition    of    any 
tetanic  symptoms,  a  finding   that   might   serve   as 
a  check,    perhaps,  upon   a  too    liberal    interpreta- 
tion of  morphological    change    in    cases    that    do 
exhibit  tetany. 


260  PARATHYROID    GLANDS 

Pellagra. — Marinesco  has  recently  described  atro- 
phy and  marked  fatty  change  in  the  external  para- 
thyroids in  two  cases  of  this  disease. 

General  Pathology. — Thompson  and  Harris,  in 
a  study  of  these  glandules  from  a  morphologic  stand- 
point in  two  hundred  and  fifty  routine  autopsies, 
state  that  they  have  been  unable  to  correlate  to  any 
extent  clinical  symptoms  and  morphological  para- 
thyroid alteration.  They  nevertheless  add  the  fol- 
lowing report  of  certain  histological  findings  in  these 
glandules  that  are  of  interest : 

Fat. — The  fat  content  of  these  glandules  is  so 
constant  in  the  adult  that  it  gives  a  distinct  yellow 
color  to  the  gland  and  serves  as  a  macroscopic  aid 
in  differentiating  parathyroids  from  lymph  nodes, 
accessory  thyroids,  or  thymus,  sympathetic  nerve 
ganglia,  or  other  bits  of  tissue  which  make  the 
search  for  these  organs  more  or  less  difficult,  espe- 
cially to  one  who  has  not  had  considerable  experience 
in  their  isolation.  Microscopically  one  should  differ- 
entiate perhaps  between  the  fatty  content  of  the 
connective  tissue  of  the  gland  and  the  fatty  content 
of  the  cells  of  the  parenchyma,  although  as  a  matter 
of  fact  it  is  doubtful  if  one  occurs  to  any  marked 
extent  without  the  other  being  present.  In  a  great 
number  of  the  glandules  there  was  a  replacement 
of  considerably  more  than  half  the  parathyroids 
with  fatty  tissue  and  in  addition,  the  principal  cells 
of  the  gland  contained  fat;  but  such  cases  showed 
nothing  clinically  that  would  serve  to  call  attention 
to  a  lack  of  parathyroid  function. 

While  it  may  be  stated  that  in  general  more  fat 
is  to  be  found  in  elderly"  individuals  than  in  those  of 


THE    PATHOLOGIC    HISTOLOGY  261 

middle  age,  still  one  would  hesitate  to  accept  the 
view  that  a  regular  and  constant  increase  of  fat  is 
an  accompaniment  of  increasing  age.  A  number 
of  glandules  in  individuals  over  sixty  years  of  age 
were  found  that  were  only  moderately  fatty,  and 
on  the  other  hand,  there  were  found  glandules  in 
patients  from  twenty  to  thirty  years  of  age  in  which 
there  was  marked  fatty  change  both  in  parenchyma 
and  stroma.  One  would  not,  therefore,  limit  the 
diagnosis  of  fatty  degeneration  to  the  earlier  years 
of  life,  although  admitting  the  increased  difficulty 
of  making  such  a  diagnosis  in  the  later  years. 

The  fat  content  is,  as  previously  stated,  so  physio- 
logically variable  that  one  hesitates  to  attempt  any 
classification  for  fatty  degeneration  of  the  glandules. 
The  most  marked  changes  in  these  cases,  the  factor 
of  age  being  kept  in  mind,  have  been  found  in  the 
following  conditions:  cirrhosis  of  the  liver;  chronic 
nephritis,  especially  chronic  parenchymatous  neph- 
ritis; chronic  heart  affections  with  the  usual  asso- 
ciated lesions ;  chronic  tuberculosis ;  diabetes.  Espe- 
cially are  the  glandules  apt  to  be  fatty  when  an  acute 
infection  is  superimposed  on  a  chronic  condition. 
The  most  constant  and  marked  fatty  change  in  any 
one  series  of  cases  was  in  five  instances  of  ascending 
infection  of  the  genito-urinary  tract  with  pyelo- 
nephrosis.  In  all  these  cases,  which  were  of  various 
ages,  marked  fatty  change  in  the  parathyroids  was 
found.  These  cases  are  representative  only  of  a 
type  of  rather  long  continued  acute  infection  where 
considerable  chronic  disease  of  the  lungs,  heart,  and 
liver  was  present. 


262  PARATHYROID    GLANDS 

The  association  of  marked,  fatty  change  in  the  para- 
thyroids .with  cases  of  infection  of  the  gall-bladder 
and  ducts,  with  extreme  jaundice  in  four  cases  of 
this  condition,  might  be  noted  in  passing.  In  ma- 
lignant diseases,  carcinoma  especially,  of  either 
comparatively  long  or  comparatively  short  duration, 
there  was  no  fixed  condition  of  fatty  content  in  the 
parathyroids.  At  times  these  organs  showed  marked 
fatty  change ;  at  times  there  was  no  apparent  increase 
of  fat.  The  same  was  true  in  regard  to  the  para- 
thyroids in  cases  dying  from  uncomplicated  acute  in- 
fectious diseases  of  short  duration  such  as  lobar  pneu- 
monia. A  case  of  tertiary  syphilis  (the  only  one  in 
this  series),  showed  marked  fatty  degeneration  of 
the  glandules. 

Colloid. — It  would  be  unfair  to  exclude  the  pres- 
ence of  colloid  unless  serial  sections  are  made  of  all 
glandules,  although  if  colloid  is  present  at  all  it  is 
usually  more  or  less  widely  distributed  in  a  given 
glandule.  Colloid  was  found  in  about  fourteen  per 
cent  of  all  cases.  This  agrees  with  the  statement  that 
the  presence  of  a  certain  amount  of  colloid  in  indi- 
viduals over  twenty  years  of  age  is  not  to  be  consid- 
ered abnormal.  The  interesting  point  in  regard  to 
colloid  is  the  fact  that  its  secretion  not  infrequently 
leads  to  appearances  in  the  parathyroid  that  makes 
circumscribed  areas  within  them  exceedingly  sug- 
gestive of  thyroid  structure.  These  areas  begin  by 
a  dozen  cells,  more  or  less,  assuming  an  alveolar  ar- 
rangement. In  the  center  so  formed  a  droplet  of 
colloid  appears.  Continued  secretion  of  colloid  pushes 
back  and  flattens  the  cells  so  that  finally  a  follicle, 
similar  to  those  seen  in  the  thyroid  gland,  appears. 


THE    PATHOLOGIC    HISTOLOGY  263 

If  enough  of  these  are  formed  in  juxtaposition,  thy- 
roid-like structure  results.  Usually,  however,  these 
colloid  follicles  are  discrete,  or  the  amount  of  colloid 
is  not  sufficient  to  alter  the  general  topography  of 
the  glandule. 

Even  though  a  picture  somewhat  like  thyroid 
structure  may  be  produced,  one  should  remember 
that  on  embryological,  anatomical;  and  physiological 
grounds  there  is  no  relationship  between  human 
thyroid  and  parathyroid,  save  that  of  propinquity. 
They  are  independent  of  each  other,  and  there  is 
no  reason  for  assuming  that  one  acts  for  the  other, 
although  it  is  probable  that  there  is  some  inter- 
action between  the  two.  There  is  no  reason  to  be- 
lieve, as  stated  by  Forsyth,  that  histologically  in- 
termediate stages  between  thyroid  and  parathyroid 
are  common,  in  the  human  being  at  least,  or  that 
the  difference  in  the  glands  is  merely  a  difference  in 
the  amount  of  secretion;  neither  have  we  reason  to 
suppose  that  the  parathyroids  exhibit  a  partial 
change  to  thyroid  structure  with  advancing  age  as 
claimed  by  Rogowitz. 

Vincent  and  Jolly  find  that  parathyroid  tissue  left 
behind  after  thyroid  extirpation  "approximates  in 
appearance  to  ordinary  thyroid  tissue,"  and  believe 
that  the  parathyroid  functionally  replaces  thyroid. 
Their  view  is  directly  opposed  by  Hagenbach,  how- 
ever, who  obtained  a  typical  cachexia  thyropriva 
when  two  parathyroids  were  left  behind. 

Thompson  and  Harris  did,  however,  find  in  this 
region  appearances  which  they  chose  to  consider 
accidents  of  propinquity  and  in  which  there  was  an 
apparent  transformation  of  one  organ  into  the  other, 


264  PARATHYROID    GLANDS 

but  which  they  considered  should  be  interpreted  on 
more  rational  grounds  than  transformation  of  para- 
thyroid into  thyroid. 

In  this  case  (which  showed  at  autopsy  caseous 
tuberculous  pneumonia,  chronic  pleuritis,  localized 
peritonitis,  and  peri-hepatitis)  there  were  fairly  firm 
adhesions  in  places  between  the  capsule  of  the  thy- 
roid and  surrounding  tissue.  The  upper  parathy- 
roids were  normal;  left  lower  not  found;  left  right 
lower  pole  showed  a  circumscribed  thickening  of 
the  surrounding  structures  and  was  excised.  Micro- 
scopically, section  of  this  showed,  on  the  outer  edge, 
fairly  typical  parathyroid  structure  penetrated  by  a 
dense  connective  tissue  stroma.  The  inner  part  of 
the  section  showed  typical  thyroid  structure  with  a 
similar  increase  of  stroma.  There  was  no  line  of 
demarcation  between  the  two,  but  one  seemed  to 
run  into  the  other  so  as  to  suggest  the  transformation 
of  parathyroid  into  thyroid  tissue.  It  seems  more 
rational  to  assume,  however,  that  a  perithyroiditis 
leading  to  proliferative  changes  in  both  glands  joined 
the  two  organs  together  in  this  peculiar  manner,  the 
connective  tissue  ingrowth  being  so  distributed  that 
both  appear  to  be  one  and  the  same  organ. 

Degenerations. — Acute  degenerative  changes  oc- 
cur in  the  parenchymatous  cells  of  the  parathyroid 
glandules,  but  a  diagnosis  of  "cloudy  swelling"  or 
"acute  degeneration"  is  to  be  made  only  when  one 
can  exclude  post-mortem  changes  and  other  adventi- 
tious factors  that  might  arise  wholly  apart  from  in- 
trinsic parathyroid  changes.  In  many  cases  the 
glandules  are  microscopically  enlarged,  are  soft  and 
pale,  or  firm  and  tense.     These  changes  are  usually 


THE    PATHOLOGIC    HISTOLOGY  265 

due  to  increased  fluid  content  (oedema)  and  are  prac- 
tically always  a  part  of  a  general  oedema  of  the  neck 
organs.  Microscopically  the  cells  in  such  glandules 
are  larger  than  normal,  the  cytoplasmic  granules  are 
more  distinct  than  usual  and  the  nuclei  large  and  pale. 
Frequently  the  usual  structure  of  the  gland  is  lost 
and  no  good  cell  pictures  obtained.  The  authors 
have  been  unable  to  fix  such  appearances  as  being  of 
significance. 

Hemorrhage. — Hemorrhage  was  found  in  these 
cases  of  Thompson  and  Harris  only  three  times.  The 
rarity  of  hemorrhage  in  adults  has  been  noted  by  Erd- 
heim,  who  found  it  seven  times  in  children  but  only 
in  one  instance  in  an  adult.  Getzowa  found  it  only 
once  in  the  adult.  Yanase  also  speaks  of  the  in- 
frequency  of  hemorrhage  in  these  glandules  in  adults 
although  he  has  been  able  to  demonstrate  it  fre- 
quently in  the  first  year  of  life,  as  previously  noted. 
Verebely  found  hemorrhage  only  once  in  the  adult 
(twice  in  children),  in  his  one  hundred  and  twenty- 
five  cases.  Benjamins  and  Peterson  only  report 
single  cases,  the  latter  in  one  hundred  autopsies. 
Our  cases  of  hemorrhage  were  found  in  connection 
with  toxic  glomerulo-nephritis,  marked  general  ane- 
mia secondary  to  syphilis,  and  acute  parenchyma- 
tous nephritis,  respectively.  In  none  of  these  cases 
was' there  any  clinical  manifestation- of  tetany. 

Fibrosis. — The  amount  of  connective  tissue  found 
in  the  parathyroids  is,  in  general,  subject  to  wide 
variation.  The  gland  may  consist  of  a  continuous 
mass  of  epithelial  cells  penetrated  by  a  considerable 
capillary  network,  unaccompanied  by  connective 
tissue,  or  there  may  be  a  continuous  reticulum  run- 


266  PARATHYROID    GLANDS 

ning  throughout  the  gland.  When  the  gland  is 
broken  up  into  distinct  islets  by  a  decided  connective 
tissue  stroma  there  is  in  the  gland  more  connective 
tissue  than  should  be  considered  normal  for  the 
structure.  Some  authors,  however,  choose  to  class- 
ify this  as  a  particular  '  'type' '  of  gland.  In  any  event 
the  widening  of  such  a  stroma  and  the  decreased 
size  of  the  islets  leads  to  the  different  degrees  of 
what  may  be  termed  "chronic  interstitial  parathy- 
roid it  is;"  or,  as  Verebely,  who  found  the  condition 
well  marked  in  two  cases,  terms  it,  "parathyroiditis 
chronica  fibrosa."  The  best  examples  of  this  con- 
dition have  already  been  described  under  primary 
infantile  atrophy. 

In  the  series  of  cases  described  by  Thompson  and 
Harris  every  possible  variation  in  connective  tissue 
content  of  these  glandules  was  met  with. 

The  cases  exhibiting  connective  tissue  increase  in 
the  parathyroids  are,  in  this  series,  almost  without 
exception  in  poorly  nourished  individuals  showing 
at  autopsy  chronic  heart  lesions  with  general  chronic 
passive  congestion,  cirrhosis  of  the  liver,  and  chronic 
tuberculosis.  However,  the  greater  number  of  cases 
exhibiting  the  above  lesions  show  no  changes  in  the 
parathyroids,  so  that  chronic  fibrous  parathyroiditis 
is  not  necessarily  an  accompaniment  of  these  condi- 
tions, although  it  may  be  most  frequently  found  in 
connection  with  such. 

That  specific  infectious  agents  may  bring  about 
this  condition  is  suggested  by  the  extreme  sclerosis 
found  in  a  lower  parathyroid  in  a  case  of  acute 
miliary  tuberculosis.  The  reaction  in  this  case  can 
be  compared  with  the  appearance  sometimes  seen  in 


THE    PATHOLOGIC    HISTOLOGY  267 

very  chronic,  tubercle  bacilli  poor,  tuberculosis  of 
lymph  nodes,  where  there  is  little  or  no  caseation  or 
tubercle  formation  but  marked  connective  tissue 
hyperplasia. 

In  the  opinion  of  these  authors  the  fact  that  even 
in  extreme  age  and  in  a  great  variety  of  severe  dis- 
eases the  parathyroids  are  so  comparatively  free 
from  lesion  is  more  noteworthy,  and  a  better  proof 
of  their  importance  than  would  be  the  frequent 
finding  of  lesions  that  would  seriously  impair  their 
function.  In  none  of  the  cases  that  showed  fibrosis 
was  there  any  clinical  manifestation  of  tetany. 


CHAPTER  XVI. 


CYSTS  AND  TUMORS. 


Cysts  occurring  in  connection  with  the  parathyroid 
glands  may  be  broadly  classified  as  (1)  retention 
cysts;  (2)  polycystic  degeneration;  (3)  cysts  arising 
either  without,  or  in  the  neighborhood  of,  the  para- 
thyroids (branchial  cysts).  The  production  of  cysts 
of  the  former  class  has  already  been  discussed  under 
colloid.  These  small  cysts  are  quite  common. 
Thompson  and  Harris  found  them  in  about  five  per 
cent  of  their  cases.  Peterson  found  cysts  six  times 
in  his  one  hundred  cases.  Cysts  have  also  been 
noted  by  Benjamins,  by  Pepere  and  by  Kohn.  The 
latter  author  was  the  first  to  describe  retention  cysts. 
They  may  be  single,  or  three  or  four  may  be  found  in 
a  single  glandule;  rarely  do  these  cysts  exceed  the 
diameter  of  a  low  power  field. 

Polycystic  degeneration  has  been  found  by  several 
authors — Schaper  in  the  parathyroid  of  a  sheep; 
Erdheim  in  an  eighty -three  year  old  woman.  Vere- 
bely  also  describes  a  similar  picture  in  the  parathy- 
roid, but  on  account  of  the  variation  in  the  lining 
epithelium  of  the  cysts  prefers  to  class  his  case  as 
a  branchial  poly  cystoma. 

It  would  seem  that  colloid  filled  spaces  are  in  gen- 
eral so  frequent  that  there  is  no  necessity  for  consid- 


CYSTS    AND    TUMORS  269 

ering  these  "retention  cysts"  in  detail  unless  they 
assume  a  number  or  size  that  brings  them  into  rela- 
tion with  the  condition  described  elsewhere,  namely : 
true  cysts  and  thyroid-like  structure. 

The  cysts  included  in  class  (3)  are  to  be  con- 
sidered as  developmental  anomalies.  Verdun  has 
contributed  extensively  to  their  embryological  de- 
velopment, and  more  recently  Erdheim  has  sought  a 
classification  for  these  branchial  cysts.  The  latter 
author  finds  two  different  types  of  cysts  in  relation 
with  the  upper  parathyroids  which  arise  from  the 
fourth  gill  pouch.  The  more  common  and  better 
known  cysts  are,  however,  in  relation  with  the  lower 
parathyroids  which  arise  from  the  third  gill  pouch. 
Verebely  describes  in  detail  two  cysts  in  connection 
with  the  upper  glandules,  one  of  which  he  terms 
a  post  branchial  cyst,  the  other  a  branchial  cyst. 

Thompson  and  Harris  found  only  two  cysts 
of  the  parathyroid  of  any  considerable  size.  The 
first  in  a  woman  seventy -two  years  old  with  atrophic 
thyroid  (lateral  lobes  measured  only  3x2.5  centi- 
meters), upper  parathyroids  in  normal  position  but 
quite  small  (5x1 .  5x .  5  millimeters) .  Left  lower  para- 
thyroid not  found.  At  the  base  of  the  right  lower 
lateral  pole  of  the  thyroid  is  a  parathyroid  gland 
forming  a  flattened  cap  to  a  cyst  which  measures 
two  by  two  by  two  and  one  half  centimeters  in  diam- 
eter. The  cyst  wall  is  lined  with  a  single  layer  of 
flattened  epithelium.  The  second  cyst  was  also  in 
connection  with  a  lower  glandule  and  practically  its 
equivalent  in  size  (7x4x3  millimeters).  This  was  a 
simple  cyst. 


270  PARATHYROID   GLANDS 

TUMORS    OF   THE    PARATHYROID    GLANDS. 

Tumors  of  the  parathyroid  glands  have  been  re- 
ported by  a  number  of  writers,  and  we  can  now  find 
in  the  literature  a  number  of  these  growths  which 
are  described  in  considerable  detail. 

The  first  of  these  was  a  tumor  described  by  de 
Santi  (1900)  as  a  rather  large  vascular  growth,  the 
structure  of  which  corresponded  to  parathyroid 
tissue.  The  tumor  grew  with  considerable  rapidity, 
but  was  classified  as  not  malignant. 

Most  of  these  tumors  represent  reproduction  of 
parathyroid  tissue,  and  should  be  designated,  per- 
haps, as  examples  of  hypertrophy  and  hyperplasia 
rather  than  classified  as  true  tumors.  Weichselbaum 
and  others  lean  toward  the  designation  of  adenoma 
for  these  growths,  although,  as  this  author  states,  a 
distinct  boundary  line  between  adenoma  and  hyper- 
plasia cannot  be  sharply  drawn.  Most  of  these 
growths  have  been  of  small  size.  In  certain  of  these 
tumors,  as  those  of  Benjamins,  of  Hulst,  and  of 
Thompson  and  Harris,  the  proof  of  parathyroid 
origin  is  lacking,  save  for  the  resemblance  of  the 
tissue  to  parathyroid  structure,  and  the  latter  au- 
thors refer  to  their  growth  simply  as  a  '  'parathyroid- 
like" tumor. 

Verebely  has  noted  the  fact  that  there  is  a  great 
similarity  between  the  cells  of  the  parathyroid  and 
rapidly-growing  parenchymatous  thyroid  nodules, 
so  that  one  must  keep  in  mind  the  question  of  con- 
genital fetal  anomalies  in  the  origin  of  these  growths ; 
such,  for  instance,  as  the  failure  of  closure  of  the 
central  canal  of  Prenant.     The  work  of  Getzowa  and 


PLATE  XXXVII 


P.  T       CYSTIC   PARATHYROID  GLANDULE. 


CYSTS    AND    TUMORS  271 

of  Langhans  has  thrown  much  new  light  upon  these 
epithelial  forms  of  malignant  struma  and  brought  up 
the  question  of  the  origin,  of  certain  types,  at  least, 
from  the  post -branchial  bodies. 

Tumors  of  the  parathyroid  glands  may  be  grouped 
primarily  as  (1)  Extrathyro ideal  (2)  Intrathy- 
roideal.  To  the  first  group  belong  the  cases  reported 
by  Erdheim,  MacCallum,  Weichselbaum,  and  Vere- 
bely. 

Erdheim's  case  occurred  in  an  eighteen  year  old 
individual  in  one  of  the  inferior  parathyroids.  It 
was  situated  below  the  lower  pole  of  the  thyroid  and 
entirely  separated  from  the  same;  it  measured  two 
and  a  half,  by  one  and  a  half  centimeters  in  diameter. 
The  tumor  consisted  of  a  fine,  faintly  vascularized 
stroma  in  which  were  imbedded  strands  and  irregu- 
lar masses  of  epithelial  cells.  The  cells  corresponded 
to  those  of  the  normal  parathyroid  and  between 
them,  here  and  there,  colloid  droplets  were  to  be 
seen;  there  was  no  definite  follicular  structure.  In 
one  part  of  the  tumor  a  small  cyst  lined  with  a  single 
layer  of  epithelium  and  having  a  fatty  content  was 
noted. 

MacCallum  reported  a  tumor  found  at  autopsy  in 
a  male,  aged  twenty-six  years,  who  died  of  uremia. 
This  tumor  was  just  below  the  lower  pole  of  the  thy- 
roid, on  the  right  side  and  separated  from  it.  It 
consisted  of  a  long,  smooth  mass  about  two  centi- 
meters in  diameter,  enclosed  in  a  delicate  capsule  and 
richly  supplied  with  blood  vessels.  The  thyroid  gland 
in  this  case  was  normal,  and  two  normal  parathyroids 
were  found.  On  microscopic  examination  the  tissue 
comprising  the  tumor  was  found  to  closely  resemble 


272  PARATHYROID    GLANDS 

parathyroid.  The  mass  was  made  up  of  strands  and 
large  groups  of  cells  separated  by  a  delicate  vascular 
stroma.  No  colloid  was  found  in  either  the  cells 
or  the  alveolar  spaces  and  the  blood  supply  was  less 
than  was  normally  present  in  the  parathyroid.  Mac- 
Callum  classified  the  tumor  as  an  adenoma. 

Goris  found  a  tumor  in  a  twenty-two  year  old  male 
consisting  of  three  closely  connected  cysts  which 
contained  colloid  and  degenerated  parathyroid  tissue. 
This  case  should  perhaps  be  classified  under  cystic 
degeneration  of  the  parathyroid  rather  than  in  this 
place. 

Von  Verebely  has  described  a  tumor  of  the  para- 
thyroid, belonging  to  the  first  group.  This  tumor 
was  found  in  a  forty-two  year  old  woman  in  whom 
three  parathyroids  were  found,  normal  in  size  and 
position.  The  tumor  appeared  as  an  oval,  flabby, 
concave  body  under  the  lower  pole  of  the  right  thy- 
roid, measuring  two  and  a  half,  by  one  and  three- 
quarters,  by  one  and  a  half  centimeters  in  diameter. 
It  possessed  a  thin,  stretched  out  capsule.  On  sec- 
tion it  was  found  to  be  made  up  of  a  soft  homo- 
geneous, vascular  tissue.  Microscopically  the  cap- 
sule gave  off  delicate  septa  ramifying  within  the 
tumor  and  connecting  with  the  perivascular  tissue, 
so  that  a  delicate  framework  was  formed,  carrying 
capillaries,  and  possessing  spaces  filled  with  epithe- 
lial cells.  The  epithelial  cells  formed  rows  and 
strands,  and  were  sometimes  arranged  in  round  or 
irregular  islets.  Three  extreme  types  of  cells,  which 
shaded  into  each  other  by  various  gradations,  were 
described  in  this  growth.  These  cells  corresponded  to 
the  type  of  principal  cells  of  the  parathyroid  for  the 


CYSTS    AND    TUMORS  273 

most  part.  The  cells  of  the  second  type  were  vacuo- 
lated, and  appeared  singly  or  in  small  groups.  The 
third  type  corresponded  to  the  functioning  cells,  and 
varied  considerably  in  size.  No  mitoses  were  to  be 
seen  in  any  of  the  described  cells. 

Weichselbaum  described  a  tumor  of  the  parathy- 
roid found  at  autopsy  in  a  woman  who  died  of  pneu- 
monia. In  this  case  both  of  the  lower  parathyroids 
and  the  right  upper  parathyroid  were  normal  in  size 
and  position.  In  the  left  upper  glandule  was  a  flat- 
tened tumor  measuring  four  and  three-tenths  by 
three  and  six-tenths,  by  one  half  to  one  centimeter 
in  diameter.  It  covered  a  part  of  the  posterior 
surface  qf  the  left  thyroid  as  well  as  the  posterior 
surface  of  the  right  thyroid.  It  was  very  soft,  and 
gray-red  in  color.  Histologically  the  tumor  consisted 
essentially  of  normal  parathyroid  structure,  with  no 
suggestion  of  malignant  tendency.  The  tumor  pos- 
sessed a  delicate  connective  tissue  capsule,  strands 
of  which  penetrated  the  mass,  separating  the  cells 
into  groups  of  different  size.  These  cells  could  be 
divided  into  four  different  types — the  first  cor- 
responding to  the  principal  cells  of  the  normal  para- 
thyroid; the  second  corresponding  to  the  functional 
cells  of  the  normal  parathyroid ;  the  third  character- 
ized by  the  grouping  of  the  cells  around  a  central 
lumen ;  and,  finally,  cell  groups  not  definitely  separ- 
ated by  a  stroma  in  which  cells  and  nuclei  were  quite 
small. 

Intrathyroideal  tumors  have  been  described  by 
Benjamins  and  by  Hulst  and,  as  previously  stated,  their 
origin  is  open  to  question,  as  are  the  other  tumors 
whose  description  follows.     The  tumor  described  by 


274  PARATHYROID    GLANDS 

Benjamins  was  in  a  fifty-seven  year  old  male;  situ- 
ated in  the  right  thyroid  lobe.  This  tumor  developed 
within  three  years  to  the  size  of  a  child's  head,  and 
recurred  after  extirpation.  This  tumor  showed  a 
connective  tissue  framework  in  which  cells  similar 
to  those  of  the  parathyroid  were  found  arranged  in 
groups ;  they  possessed  a  pale  nucleus  with  clear  • 
protoplasm  and  showed  a  tendency  toward  palisade 
arrangement ;  they  were  a  little  larger  than  the  nor- 
mal parathyroid  cells .  Mitoses  were  rarely  seen  in  the 
cells.  Here  and  there  small  masses  of  colloid  were 
found.  A  normal  parathyroid  was  found  in  the 
capsule  of  the  tumor. 

The  tumor  described  by  Hulst  was  found  in  a  very 
old  woman,  in  the  right  lobe  of  the  thyroid,  postero- 
medial, about  the  height  of  the  isthmus  of  the  gland. 
It  measured  two  and  a  half,  by  two  and  a  half,  by 
two  centimeters,  and  was  inclosed  in  a  calcified  cap- 
sule. Microscopically  this  tumor  consisted  of  a 
stroma  rich  in  blood  vessels  and  made  up  of  cells  of 
two  types;  the  larger  were  polygonal  and  stained 
deeply  with  eosin,  and  their  nuclei  showed  signs  of 
degenerative  change;  the  smaller  which  appeared  in 
groups  among  the  other  cells  possessed  little  proto- 
plasm, and  showed  an  eccentric  nucleus  which  stained 
intensively.  There  were  various  gradations  between 
these  two  types  of  cells.  Mitoses  were  not  found. 
The  author  characterized  the  tumor  as  an  adenoma 
arising  from  parathyroid;  he  makes  no  mention, 
however,   of  other  parathyroid  glands  in  this  case. 

Askanazy  has  called  attention  to  a  tumor  appar- 
ently derived  from  parathyroid  tissue  which  he  found 
in  a  case  of  ostitis  deformans. 


CYSTS    AND    TUMORS 


275 


Thompson  and  Harris  have  described  a  tumor 
possessing  a  parathyroid-like  structure  which  was 
removed  at  operation  so  that  no  careful  dissection 
of  the  neck  could  be  made.  These  authors  state: 
"The  extreme  similarity  of  the  greater  part  of  the 
structure  to  parathyroid  tissue  justifies  its  discussion 
in  this  place  although  certain  parts  of  it  suggest  the 
possibility  of  its  origin  from  the  post  branchial  body. 


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Fig.    69.     Section   of   parathyroid   tumor,,    magnified  400   times. 
(Thompson  and  Harris.) 

We  have  chosen  to  call  the  growth  simply  a  para- 
thyroid-like tumor  and  regret  that  circumstances 
were  such  that  neither  a  careful  topographical  study 
of  the  neck  region  could  be  made  in  the  case,  nor 
even,  owing  to  the  way  the  tumor  was  received,  could 
the  differential  histological  stud)7-,  especially  in  re- 


276  PARATHYROID  GLANDS 

gard  to  glycogen  content,  be  done  that  was  desired. 

"The  specimen  is  a  nodular  encapsulated  mass 
(15x10x6  centimeters),  weighing  two  hundred  and 
fifty  grams.  Some  of  the  nodules  push  sharply  above 
the  level;  others  are  low,  broad,  and  seemed  fused 
together.  The  larger  reach  a  diameter  of  four  cen- 
timeters; the  smaller  measure  one-half  to  one  centi- 
meter. The  tumor  is  firm  throughout.  The  cap- 
sule is  thick,  fibrous,  and  tense,  and  entirely  covers 
the  mass  with  the  exception  of  an  area,  four  by  five 
centimeters,  which  represents  the  severed  point  of 
attachment.  This  capsule  dips  between  the  nodules 
and  marks  their  outlines.  The  color  is  brownish 
yellow,  mottled  by  scattered  hemorrhagic  areas  in 
and  upon  the  nodules.  There  are  no  large  or  con- 
gested vessels  to  be  seen. 

"On  section  the  mass  is  found  to  consist  of  many 
discrete  and  confluent  light  brownish  yellow  areas 
separated  more  or  less  by  fibrous  trabecule.  These 
areas  correspond  to  the  superficial  nodules.  They 
are  firm,  homogeneous,  and  friable ;  their  cut  surface 
presents  a  milky  exudate,  rich  in  cells.  Variations 
in  the  appearance  of  these  areas  depend,  in  the  main, 
upon  the  blood  content.  Some  are  pale  and  blood- 
less, some  show  congested  capillaries;  others  con- 
tain bright  red  or  dark  brown  areas  of  hemorrhage. 
In  one  nodule  the  cut  surface  is  marked  by  translu- 
cent, silver-gray  anastomosing  bands  of  connective 
tissue  which  arise  from  the  capsule.  There  are  a 
few  small  cysts  filled  with  a  gelatinous  semi-solid 
material. 

"The  capsule,  which  on  the  surface  is  distinct  both 
in  color  and  structure,  loses  its  fibrous  character  as 


CYSTS    AND    TUMORS  277 

it  passes  into  the  mass  and  fades  into  a  broad  brown- 
ish yellow  band.  Numerous  small  blood  vessels 
course  along  the  connective  tissue  trabecular. 

"For  microscopical  study  a  segment  about  five 
millimeters  in  thickness,  cut  from  the  median  zone, 
was  carefully  plotted  so  that  in  the  end  it  was  possible 
to  reconstruct  the  entire  cut  surface  of  the  gross 
specimen.  Histologically,  the  specimen  is  an  epithe- 
lial tumor  in  which  the  cells  are  arranged  as  tubules 
or  in  nests  and  cords  resembling  the  structure  of 
parathyroid  glandule.  The  connective  tissue  in 
places  is  prominent  and  forms  anastamosing  septa 
between  the  epithelial  islands.  In  other  parts  it 
is  present  only  as  a  delicate  basement  membrane, 
or  very  fine  interlacing  reticulum  between  the  cords 
and  clusters  of  loosely  lying  epithelial  cells.  Differ- 
ent lobules  show  wide  variations  in  this  proportionate 
distribution  of  epithelial  cells  and  stroma.  In  an 
individual  lobule  this  relationship  is  constant.  The 
epithelial  cells  vary  in  diameter  from  twenty  to 
twenty-five  microns.  The  nuclei  measure  from  four 
to  eight  microns  and  stain  deeply.  The  protoplasm 
is  vacuolated  and  stains  lightly.  As  a  rule,  the  cell 
boundary  is  not  sharply  defined.  For  the  most 
part  the  cells  are  cuboidal  or  columnar  and  rest  upon 
a  distinct  but  delicate  basement  membrane. 

"The  structural  formation  follows  the  type  of  a 
simple  gland  with  a  small  lumen,  or  the  cells  are 
grouped  into  small  solid  nests  of  six  or  more  cells. 
From  this  original  gland-like  type,  two  variations 
arise.  In  the*  one  the  lumen  becomes  dilated,  with 
the  formation  of  numerous  small  cysts,  the  epithelium 
becomes  flattened,  and  papuliferous  outgrowths  arise 


278  PARATHYROID    GLANDS 

from  the  walls.  In  the  other  variation  the  cells  are 
freed  from  their  attachment  to  the  basal  membrane 
and  appear  as  compact  or  loose  clusters,  cords  and 
nests;  the  lumen  disappears  and  all  structural  regu- 
larity is  lost. 

"For  the  most  part  the  tumor  is  rich  in  capillaries 
upon  whose  delicate  walls  the  cells  are1  attached  di- 
rectly. In  a  few  nodules  the  blood  supply  is  sur- 
prisingly scant,  entire  fields  being  apparently  free 
from  determinable  vessels.  The  hemorrhagic  areas 
are  numerous  in  certain  lobules,  the  blood  lying  in 
large  lakes  and  tubules  and  nests.  The  absence  of 
large  blood  vessels  with  well  developed  walls  is 
striking." 

DaCosta  found  in  a  female  aged  thirty-two  years, 
on  the  right  side  of  the  neck,  a  tumor  about  as  large 
as  an  orange.  His  tumor  is  described  as  follows: 
"It  passes  to  some  extent  back  of  the  level  of  the 
upper  border  of  the  thyroid  cartilage  above.  It  also 
passed  to  one  centimeter  to  the  left  of  the  median 
line.  It  was  smooth,  regular  in  outline,  except  for 
a  bulb-like  projection  at  its  lower  anterior  portion; 
and  of  firm  consistency  throughout.  The  growth 
was  in  extremely  close  relation  with  the  recurrent 
laryngeal  nerve  of  the  right  side,  and  great  difficulty 
was  experienced  in  effecting  a  separation  between 
the  nerve  and  the  tumor  mass.  No  parathyroids 
were  identified.  The  tumor  was  brownish  yellow  and 
irregular,  and  presented,  in  front  of  the  lower  por- 
tion, a  bulb-like  projection  the  size  of  a  walnut, 
which  was  somewhat  softer  and  decidedly  darker 
than  the  remainder  of  the  mass,  but  apparently  a 
portion  of  it." 


CYSTS    AND    TUMORS  279 

The  growth  is  described  histologically  as  consist- 
ing of  parathyroid  gland  (tissue),  surrounded  by  a 
fibrous  capsule.  The  epithelial-like  cells  were  ar- 
ranged in  fairly  distinct  columns,  or  masses  separated 
by  thin  walls  of  vessels,  or  vascular  intercellular 
tissue.  In  some  areas,  the  tissue  was  arranged  in 
the  form  of  acini,  lined  with  cuboidal  or  polygonal 
cells ;  although  even  in  these  instances,  there  was  no 
sharp  demarcation  between  neighboring  cells.  The 
protoplasm  of  most  of  the  cells  was  granular  or  vesi- 
cular, and  showed  weak  affinity  for  acid  stains.  The 
nuclei  of  these  cells  were  small  masses  of  material 
that  gave  the  staining  reaction  of  chromatin.  In  a 
number  of  the  acini  were  small  masses  of  colloid. 
Bands  of  fibrous  tissue,  enclosing  numerous  areas  of 
weakly  acidophile  substance,  or  distinct  masses  of 
cells,  were  distributed  through  portions  of  the  sec- 
tion. Many  areas  of  hemorrhage  appeared  at  va- 
rious points  in  the  section.  Most  of  these  were  re- 
cent; but  at  a  few  points  there  were  degenerative 
changes  in  the  bordering  gland  tissue.  Separated 
from  the  parathyroid  structure  by  a  broad,  distinct 
band  of  fibrous  tissue,  containing  many  large  blood 
vessels,  was  a  portion  of  attached  thyroid. 

De  Paoli  has  reported  two  tumors  of  the  para- 
thyroids occurring  in  males  aged  twenty-one  and 
forty-one  years,  respectively.  These  tumors  are 
described  as  being  composed  equally  of  thyroid  and 
parathyroid  tissue. 

Pepere  has  reported  two  cases  of  angioma  of  the 
parathyroid  as  well  as  two  cases  of  myoma  and  a 
lymphoma  of  these  glandules.  The  same  author  also 
described  a  parathyroid  adenoma  the  size  of  a  large 


280  PARATHYROID   GLANDS 

apple.  A  similar  tumor,  but  smaller  in  size  (1.5 
cm.  x  7  min.  x  5  min.),  has  been  described  by  Claude 
and  Schmiergeld.  Tumors  have  also  been  described 
by  Makai,  by  Walther  and,  quite  recently,  by  Berard 
and  Alamartine,  who  also  give  a  considerable  review 
of  the  literature, 

Metastatic  involvement  of  the  parathyroids  from 
malignant  growths  arising  elsewhere  has  been  re- 
ported by  Konigstein,  from  a  bronchial  carcinoma 
which  involved  thyroid  and  three  parathyroids; 
by  Pepere,  two  cases,  from  a  breast  carcinoma  and 
a  thyroid  carcinoma;  and  by  Thompson  from  a 
breast  carcinoma  in  which  there  was  involvement  of 
all  four  glandules.  In  none  of  these  cases  was  tetany 
observed. 


CHAPTER  XVII. 


RELATION  OF  THE  PARATHYROID  GLANDS 
TO  POSTOPERATIVE  TETANY. 


It  is  rather  a  peculiar  coincidence  that  the  discov- 
ery of  the  parathyroid  glands  by  Sandstroem  in 
Upsala  and  the  first  description  of  tetany  following 
goitre  extirpation  by  Weiss  in  Vienna,  should  have 
occurred  in  the  same  year.  Ten  years  elapsed,  how- 
ever, before  the  relationship  of  these  observations 
was  disclosed.  It  was  just  about  this  time  that  opera- 
tions for  goitre,  which  had  previously  been  uncom- 
mon, were,  thanks  to  the  work  of  Billroth  and  Kocher, 
becoming  more  frequent.  Following  such  opera- 
tions it  was  noted  that  either  cachexia  or  tetany 
might  manifest  itself. 

Also  for  many  years  it  had  been  noted  that  certain 
animals  after  thyroidectomy  showed  convulsive  or 
tetanic  symptoms  which  quickly  led  to  death,  but 
no  one  had  considered  these  symptoms,  either  in 
*  animals  or  man,  due  to  anything  other  than  removal 
of  the  thyroid  gland.  Schiff  (1883),  performed  a 
complete  thyroidectomy  (which  of  necessity  included 
the  parathyroids)  on 'sixty  dogs,  fifty-nine  of  which 
died  in  tetany  and  convulsions  as  a  result  of  the 
operation.  Horsley  in  1892,  in  ignorance  of  the  work 
of  Gley  on  the  parathyroids  which  was  then  just 
appearing,  made   the    following-  statement    in    con- 


282  PARATHYROID    GLANDS 

nection  with  thyroidectomized  apes:  "In  the  mon- 
key I  have  found  that,  as  a  rule,  the  animal,  after 
complete  thyroidectomy,  appears  perfectly  well  for 
about  five  days.  Then  there  is  noticed  a  slight 
fibrillation  of  the  intrinsic  muscles  of  the  hands, 
feet,  and  jaws  following  this  order  in  successive  in- 
vasion. As  a  rule  the  fibrillation  soon  becomes  a 
constant  tremor.  The  constant  tremor  is  soon  added 
to  by  a  series  of  powerful  clonic  spasms.  This  par- 
oxysmal stage  usually  appears  about  the  second  or 
third  day  after  the  tremors  are  first  noted,  and  per- 
sists about  twenty  days.  They  gradually  fall  in 
force,  reassume  the  type  seen  at  their  onset  and  dis- 
appear sometimes  as  much  as  ten  days  before  death." 

Another  suggestive  picture  of  a  thyroidectomized 
ape  is  given  by  Langhans,  who  thus  described  the 
animal:  "Ich  habe  die  Tiere  vielfach  gesehen,  wo 
sie  hulflos  auf  dem  Bo  den  sassen,  zum  Theil  mit 
Zwangsbewegungen,  namentlich  des  Kopfes  itnd  selbst 
des  ganzen  Korpers  nach  links,  ein  rechtes  mitleid 
erregendes  Bild." 

In  herbivora,  after  the  removal  of  the  thyroid  no 
such  accidents  occurred.  We  now  know  that  a  con- 
siderable amount  of  parathyroid  tissue  must  be 
present  in  sheep  and  goats  outside  the  thyroid  gland, 
and  in  the  rabbit  two  of  the  parathyroids  are  situ- 
ated at  some  distance  from  the  thyroid,  so  that  they 
were  always  left  behind  in  removal'  of  this  latter 
gland.  Therefore  it  was  the  lack  of  removal  of  all 
parathyroid  tissue  in  these  animals  that  was  the 
reason  for  the  lack  of  tetany,  and  not  the  fact  that 
animals  feeding  on  vegetable  diet  were  immune  to 


POSTOPERATIVE    TETANY  283 

these  symptoms,  while  animals  feeding  on  a  meat 
diet  succumbed  to  them. 

At  this  point  begins  our  second  important  epoch 
in  the  history  of  the  parathyroid  glands,  which  was 
inaugurated  by  the  discovery  of  Gley,  in  1891,  that 
the  tetanic  symptoms  which  appeared  after  removal 
of  the  thyroid  were  not  due  to  the  loss  of  the  thyroid 
but  were  due  to  the  loss  of  the  parathyroid  glands 
which  were  removed  with  the  thyroid. 

Gley  demonstrated  that  in  the  rabbit  there  were 
two  parathyroids  separate  from  the  thyroid  and  if 
these  were  removed  together  with  the  thyroid,  which 
contained  the  other  two  parathyroids,  the  same 
tetanic  symptoms  arose  in  the  rabbit  as  had  been 
obtained  in  the  dog. 

Gley  removed  in  his  first  experiments  both  the 
thyroids  and  the  parathyroids  from  sixteen  rabbits. 
Fourteen  of  these  animals  following  such  treatment 
showed  rapidly  fatal  symptoms,  which  began  within 
twenty-four  hours  after  operation  and  led  to  death 
in  a  few  hours.  Gley  continued  these  experiments 
and,  in  all,  removed  the  parathyroids  in  more  than 
fifty  rabbits.  When  the  external  parathyroids  alone 
or  the  thyroid  lobes  alone  were  removed  there  was 
no  tetany,  but  when  these  external  bodies  plus  thy- 
roid (which  contained  the  remaining  parathyroids) 
were  removed  tetany  and  death  resulted.  It  is  to 
be  noted  that  the  islets  of  parathyroid  tissue  that 
are  sometimes  found  in  the  thymus,  were  then  un- 
known, and  therefore  in  the  rabbits  that  survived 
all  the  parathyroid  tissue  was  probably  not  removed. 

Gley  also  showed  that  in  the  dog  if  the  thyroid 
was  removed  and  the  parathyroids  were  left  intact, 


284  PARATHYROID    GLANDS 

the  animal  did  not  show  acute  symptoms,  while  if 
the  parathyroids  were  subsequently  removed  the 
usual  fatal  tetany  resulted.  Similar  results  were  ob- 
tained in  the  rabbit.  When  the  parathyroids  were 
removed  a  month  subsequent  to  the  thyroid  removal, 
the  animal  .died  with  acute  symptoms. 

In  all  this  work,  however,  Gley  failed  to  recog- 
nize the  internal  parathyroids  which  are  within  the 
thyroid  lobes,  and  therefore,  he  concluded  that  the 
negative  effect  of  removing  the  thyroid  alone  was 
due  to  the  vicarious  action  of  the  external  parathy- 
roids. 

These  researches  of  Gley  were  begun  in  1891,  and 
covered  a  number  of  years.  Soon  after  his  first  ar- 
ticles appeared,  a  number  of  other  investigators  took 
up  this  fascinating  problem. 

•  Hofmeister  confirmed  the  work  of  Gley  in  so  far 
as  to  find  that  severe  symptoms  and  death  followed 
the  extirpation  of  the  parathyroid  glands;  he  did 
not  observe  the  compensatory  hypertrophy  of  the 
organ  after  extirpation  of  the  thyroid  that  Gley 
had  described. 

Moussu  in  a  number  of  experiments  on  the  rabbit 
and  cat  brought  forward  proof  that  thyroid  and  para- 
thyroid .each  possessed  a  distinct  function ;  the  loss 
of  the  thyroid  was  followed  by  chronic  trophic  dis- 
turbances, such  as  myxcedema  and  marked  cachexia, 
while  extirpation  of  all  the  parathyroids  led  to  acute 
tetanic  symptoms  and  death.  This  teaching,  which 
involved  a  strong  separation  between  the  symptom 
complex  of  thyropriva  and  of  parathyropriva  was 
for  a  time  a  much  vexed  question.  Moussu's  ex- 
periments, which  comprised  fifty-five  complete  para- 


POSTOPERATIVE    TETANY  285 

thyroidectomies,  principally  on  dogs,  were  followed 
by  tetanic  death  in  thirty-three  cases.  In  the  ani- 
mals which  survived,  the  author  considered  that  the 
operations  were  incomplete,  as  at  autopsy  one  or 
more  parathyroids  that  had  escaped  ablation  were 
found  in  a  number  of  instances. 

Moussu  gives  the  following  description  of  para- 
thyroid insufficiency  in  a  dog  where  ablation  was 
not  quite  complete:  "Appetit  capricieux,  elevation, 
legere  et  permanente  de  la  temperature,  augmentation 
du  nombre  des  battements  cardiaques,  tacky  car  die, 
dyspnee,  polypnee  des  que  les  sujets  sont  soumis  a 
un  exercice  un  peu  actif:  secousses  fibrillaires  ou 
crampes  musculaires  momentanees,  albuminuric  legere 
et  inconsiante,  etc.'1'' 

Christ iani  extirpated  the  parathyroids  of  the  rat, 
together  with  the  thyroid,  and  observed  with  great 
regularity  death  in  tetany  after  the  operation. 

Kohn,  in  1895,  published  a  most  important  work 
on  the  parathyroid  glands  in  which  he  gave  us  a  more 
perfect  knowledge  of  the  anatomy  of  these  bodies 
than  we  had  previously  possessed,  and  definitely 
established 'the  independence  of  these  organs  which 
up  to  this  time  even  Gley  himself  despite  his  experi- 
mental work  had  continued  to  regard  as  embryonic 
thyroid.  After  the  publication  of  Kohn's  paper  es- 
tablishing the  identity  of  the  "internal"  as  well  as 
the  "external"  parathyroids,  a  more  sure  basis  for 
experimental  work  was  offered. 

As  a  result  of  this  work  of  Kohn,  Vassale  and  Gen- 
erali  for  the  first  time  removed  all  four  parathyroid 
glands  without  removing  the  thyroid.  These  ex- 
periments were  done  on  ten  cats  and  nine  dogs  with 


286 


PARATHYROID   GLANDS 


the  following  results.  Of  the  ten  cats  only  one  sur- 
vived (and  this  one  developed  chronic  cachexia) ;  the 
other  nine  died  as  a  result  of  the  operation  with  con- 
vulsive symptoms  (fibrillary  tremors,  muscular 
twitchings,  depression,  rigid  and  staggering  gait, 
anorexia,  tachycardia,  loss  of  weight  and  death). 
The  maximum  time  of  death  was  ten  days.  The  nine 
dogs  all  died  in  less  than  eight  days;  usually  on  the 


' "  ''Xl'S^ik 


Fig.  70.     Persistent  islet  of  parathyroid  tissue  with  granulation 
tissue  twenty-eight  days   after  mass  ligation  of  glandule. 

third  or  fourth  day  with  the  respiratory  and  con- 
vulsive symptoms  that  are  now  so  well  known. 

Vassale  and  Generali  supplemented  their  first  ex- 
periments by  a  series  of  two-stage  operations  on  a 
number  of  animals.  They  found  the  results  were  the 
same  following  total  parathyroidectomy  if  the  glands 
were  removed  in  this  way  as  were  obtained  in  the 
first  experiments,  save  that  the  dog  survived  a  little 
longer  after  the  final  complete  parathyroid  removal. 


POSTOPERATIVE    TETANY  287 

Out  of  three  dogs,  two  survived  for  twelve  days  after 
the  second  operation,  the  third  died  on  the  fifth  day. 
Out  of  four  dogs  in  which  two  parathyroids  were 
left  there  were  no  symptoms  save  in  one  instance 
where  a  little  transitory  rigidity  occurred  which  soon 
cleared  up.  Out  of  two  dogs  in  which  a  single  para- 
thyroid was  left  one  presented  transient  symptoms, 
the  other  no  symptoms  whatever. 

Rouxeau  removed  the  parathyroids  in  twenty-one 
rabbits  leaving  the  thyroid  intact  and  only  three  of 
these  animals  escaped  death.  The  symptoms  were 
the  same  in  general  as  when  complete  thyro-parathy- 
roidectomy  was  performed.  The  author  concluded 
from  this  that  in  the  rabbit  parathyroidectomy  is 
a  grave  offense,  while  removal  of  the  thyroid  is  in- 
offensive. 

Since  that  time  these  experiments  have  been  fre- 
quently repeated  and  always  with  analogous  results. 
Among  these  early  workers  may  be  mentioned  De- 
Quervain,  Verstraeten  and  Vanderlinden,  Paladino, 
Cadeac,  Guinard,  Capobianco,  Edmunds  and  Van- 
Ecke.  The  details  of  the  early  work  may  be  found 
in  the  very  complete  monograph  of  Jeandelize  which 
includes  as  well  experiments  of  his  own.  Jeandelize 
was  the  first  to  make  a  sharp  distinction  between 
the  chronic  symptoms  that  follow  thyroid  removal 
and  the  acute  symptoms  that  follow  parathyroid 
removal  and  to  establish  the  independence  of  these 
latter  organs. 

Although,  with  the  earlier  workers,  the  rabbit  was 
the  favorite  animal  for  experimentation,  the  dog, 
owing  to  its  larger  size  and  its  more  direct  connection 
of  thyroid   and   parathyroid   has  been  the   animal 


288  PARATHYROID    GLANDS 

most  generally  employed  by  later  investigators. 
Gley  himself  has  used  the  dog  in  a  number  of  his  ex- 
periments. It  is  well  to  remember,  however,  that 
in  many  cases  in  this  animal  the  glandules  may  be 
so  situated  as  to  make  a  total  parathyroidectomy 
impossible.*  Not  only  may  there  be  accessory  para- 
thyroids buried  in  thyroid  gland  but  aberrant  para- 
thyroids have  been  found  at  times  quite  a  distance 
removed  from  the  thyroid. 

Lusena  was  able  to  produce  tetany  in  nineteen 
dogs  by  parathyroidectomy,  which  was  always  rap- 
idly fatal,  (three  days  on  the  average  after  opera- 
tion). Walter  Edmunds  on  the  contrary  had  of 
nine  dogs  similarly  operated  on,  four  which  survived. 
Such  apparent  discrepancies  can  only  be  accounted 
for  by  the  lack  of  complete  parathyroid  removal 
which  is  to  be  accomplished  only  by  the  most  care- 
ful operative  procedure. 

D.  A.  Welsh  removed  the  four  parathyroids  in 
the  cat  and  obtained  severe  and  fatal  symptoms; 
even  with  one  parathyroid  left  in  situ  the  experi- 
ment was  fatal  for  some  of  these  animals.  If  two 
parathyroids  were  left  no  serious  acute  symptoms 
resulted. 

Pineles  operated  on  the  ape,  cat  and  rabbit.  He 
noted  in  the  ape  that  the  symptoms  were  of  more 
chronic  character  than  in  the  other  animals.  His 
operations  were  done  for  the  most  part  in  two  or 
three  stages;  tetanic  death  was  obtained  only  after 

*Gley  noted  14  variations  in  the  situation  of  the  glandules  in  33  dogs,  and 
Alquier  found  the  classic  situation  of  the  bodies  only  9  times  in  15  dogs.  Acces- 
sory glandules  are  at  any  time  liable  to  complicate  the  work.  Vassale  found  one 
on  the  right  side  of  the  cricoid  at  the  first  tracheal  ring,  five  in  the  mediastinum, 
three  on  the  posterior  surface  of  the  aorta.  Pianca  found  parathyroids  on  the 
aortic  trunk.  MacCallum,  and  Thompson  and  Leighton  have  repeatedly  called  at- 
tention to  extra  parathyroids. 


POSTOPERATIVE    TETANY  289 

removal  of  all  parathyroid  tissue,  the  loss  of  three 
parathyroids  gave  rise  to  practically  no  symptoms. 
In  two  apes  in  which  all  parathyroids  were  removed, 
a  progressive  tetany  developed  with  flaccid  par- 
alysis and  contraction  with  final  apathy,  spasm 
and  death.  Apes,  from  which  the  whole  thyroid  and 
nearly  all  the  parathyroid  tissue  was  removed, 
showed  trophic  disturbances,  such  as  falling  of  the 
hair,  anemia,  skin  ulcer,  and  oedema  of  the  upper 
eyelids.  Cats,  from  which  all  the  parathyroids  were 
removed,  died  on  an  average  in  five  and  a  half  days 
in  acute  tetany.  If,  in  the  cat,  the  entire  thyroid 
and  only  a  part  of  the  parathyroid  was  removed, 
apathy  and  trophic  disturbance  appeared,  but  no 
muscle  spasm.  As  result  of  these  experiments, 
Pineles  concluded  that  fatal  tetany  resulted  from 
extirpation  of  the  parathyroid  glands,  while  trophic 
disturbances  arose  from  the  loss  of  the  thyroid  sub- 
stance. 

Walbaum  obtained  results  similar  to  those  of  the 
authors  previously  cited.  His  results  will  be  dealt 
with  more  fully  in  the  chapter  on  parathyroid  trans- 
plantation, as  will  also  the  results  of  Biedl  whose 
work  on  apes,  as  well  as  on  the  dog  and  fox,  is  in 
line  with  that  previously  cited. 

We  may  mention  in  passing  that  fatal  results  have 
been  obtained  following  parathyroidectomy  in  birds 
by  Doyon  and  Jouty,  and  in  the  turtle  by  Doyon 
and  Kareff . 

MacCallum  performed  either  complete  or  partial 
parathyroidectomy  on  twenty  dogs.  His  classic 
description  of  the  symptoms  in  the  parathyroidec- 
tomized  animals  isasfollows:  "Beginning with symp- 


290  PARATHYROID    GLANDS 

toms  of  unrest  and  anxiety  with  slight,  twitchings  of 
the  muscles  here  and  there  and  fibrillary  tremors  of 
the  tongue,  the  animal  rapidly  passes  into  a  state 
in  which  the  most  violent  tetanic  spasms  of  all  the 
muscles  occur.  The  dog  is  able  to  walk  at  first  but 
rather  stiffly,  the  hind  legs  being  especially  awkward 
and  beyond  his  control,  frequently  with  a  sudden 
twitch,  they  slip  from  under  him  and  bring  him 
down  upon  the  floor.  Sometimes  in  walking  about 
or  climbing  stairs  the  dog  suddenly  falls  to  the  floor 
in  an  epileptiform  convulsion,  the  legs  are  stretched 
out  rigid,  the  head  stretched  forward,  all  the  mus- 
cles of  the  neck  being  thrown  into  a  tetanic  con- 
traction— breathing  stops  for  a  few  moments  and 
is  then  gradually  resumed,  the  legs  finally  relax  and 
the  dog  recovers  and  walks  about  again.  Usually 
however,  the  onset  of  tetany  is  more  gradual  and 
continuously  progressive  and  from  the  condition  in 
which  spastic  walking  is  possible  the  dog  goes  on 
to  that  stage  in  which,  with  all  the  muscles  rigid  and 
twitching  violently,  he  is  unable  to  stand  at  all.  The 
most  violent  trismus  with  snapping  of  the  jaws  ap- 
pears and  the  tongue  is  often  bitten;  saliva  pours 
from  the  mouth;  all  the  facial  muscles  twitch  and 
the  eyes  project  from  the  fact  that  the  upper  lid 
is  much  retracted.  Respiration  is  profoundly  af- 
fected and  the  dogs  appear  to  stretch  out  their  heads, 
panting  for  breath.  The  rate  of  respiration  is 
greatly  increased,  even  up  to  200  or  250  a  minute. 
With  this  there  is  no  sign  of  cyanosis  and  the  blood 
is  readily  arterialized  by  shaking  up  in  the  air.  Ex- 
haustion soon  supervenes  and  the  convulsions  be- 
come less  violent  and  the  respiration  less  rapid,  so 


POSTOPERATIVE    TETANY  291 

that  if  the  animal  does  not  die  in  the  height  of  the 
attack  he  lies  relatively  quiet  for  a  time  before 
death." 

Vassale  and  Donaggio  found  in  the  spinal  cord  of 
six  parathyroidectomized  dogs  a  microscopic  alter- 
ation (after  Mueller's  fixation)  which  they  con- 
sidered a  degeneration  in  the  crossed  pyramidal 
tracts  identical  in  situation  with  that  following  abla- 
tion of  the  motor  cortex,  and  also  a  similar  change 
in  the  posterior  tracts.  This  apparent  degeneration, 
however,  could  not  be  demonstrated  microscopically 
with  either  the  Marchi  or  the  Weigert-Pal  method. 
With  a  nigrosin  stain  the  axis  cylinders  showed 
swelling  and  a  granular  appearance,  and  the  myeline 
sheath  showed  atrophy  and  did  not  stain  well. 

Russell  examined  the  brain  and  cord  of*  seven  dogs 
which  died  of  tetany  after  parathyroid  removal  and 
found  rather  extensive  chromatolysis,  shrinkage  and 
distortion  of  the  pyramidal  cells  and  increase  in  the 
number  of  neuroglia  cells.  He  concluded  that  the 
anatomical  alterations  were  sufficiently  well  marked 
to  afford  a  basis  for  the  functional  changes  which 
led  to  tetany. 

Edmunds  also  found  changes  in  the  brain  and  cord 
of  parathyroidectomized  dogs.  The  Nissl  bodies 
were  no  longer  defined;  chromatolysis  was  striking. 
Sometimes  the  substance  took  the  stain  deeply;  in 
some  cells  the  chromatophilous  substance  was  ab- 
sent. Swelling  of  the  nucleus  and  various  stages  of 
destruction  was  observed.  The  changes  are  similar 
to  those  observed  after  acute  poisoning. 

Alquier  and  Theunveny  found  that  in  dogs  after 
partial  parathyroidectomy  the  menstruation  periods 


292  PARATHYROID    GLANDS 

were  less  frequent  and  duration  brief,  and  conception 
more  difficult  to  obtain.  Study  of  the  ovaries  failed 
to  show  any  changes  after  these  operations. 

Manca  reports  the  observation  of  changes  in  the 
kidney  in  various  animals  after  complete  thyro- 
parathyroidectomy.  These  changes  are  not  specific 
and  appear  sometimes  in  parenchymatous,  sometimes 
in  interstitial,  form. 

Christens  may  also  be  cited  as  contributing  to  the 
etiology  of  the  parathyroid  glands  in  the  produc- 
tion of  tetany  by  experiments  on  the  cat  and  goat. 

Berkeley  has  removed  the  parathyroid  glands  in 
over  seventy-five  rabbits,  seven  dogs  and  fourteen 
cats.  While  he  usually  obtained  lethal  results,  he 
sometimes  noted  recovery  in  the  animals  even  after 
they  had  exhibited  severe  symptoms.  He  concluded 
that  in  these  instances  a  remnant  of  gland  left  be- 
hind had  time  to  hypertrophy. 

Erdheim  has  contributed  one  of  the  most  inter- 
esting, important  and  complete  articles  that  have 
appeared  on  the  subject  of  postoperative  tetany  in 
parathyroidectomized  animals.  His  experiments  in- 
clude partial  and  total  operations  in  fifty  rats.  The 
parathyroid  glands  were  destroyed  in  these  animals 
by  a  fine  cautery.    . 

Erdheim  made  careful  serial  microscopic  sections 
of  the  neck  organs  in  all  these  cases  exhibiting  tetany 
and  demonstrated  conclusively  the  presence  of  thy- 
roid and  the  absence  of  parathyroid;  thus  establish- 
ing beyond  a  doubt  the  parathyroprivic  nature  of 
the  tetany. 

Different  grades  of  tetanic  symptoms  appeared 
following  his  operations.     Usually  symptoms  were 


POSTOPERATIVE    TETANY  298 

noted  in  the  first  twenty-four  to  thirty-six  hours, 
consisting  of  tremor  and  spasm,  continual  movement 
of  the  whole  body  musculature,  shaking,  tonic  spasm, 
and  status  epilepticus.  In  twenty-nine  rats  both 
parathyroids  were  destroyed  (this  animal  possesses 
only  two  parathyroids),  and,  in  all  but  two  cases, 
tetany  appeared  in  between  three  and  seven  days. 
In  some  of  these  animals  where  a  third  (accessory) 
parathyroid  was  found  in  the  apex  of  the  thymus, 
this  glandule  seemed  to  have  no  influence  on  the  course 
of  the  tetany. 

In  twelve  of  these  cases  where  total  parathyroid- 
ectomy was  performed  the  death  of  the  animal  was 
delayed,  occurring  in  fifty -four  to  one.  hundred  and 
sixty-two  days.  In  these  cases  the  tetany  showed 
an  outspoken  chronic  character.  In  addition,  in 
these  twelve  animals,  there  occurred  notable  trophic 
disturbances,  especially  in  the  incisor  teeth.  Enamel 
defects  showed  themselves  as  white  flakes  on  the 
normally  yellow  colored  tooth.  In  addition  the 
teeth  became  brittle,  and  gave  rise  to  considerable 
pain  if  broken  off  within  the  alveolar  process.  Gan- 
grenous stomatitis  was  noted  in  the  lower  jaw  about 
.the  broken  off  roots  while  the  teeth  of  the  upper  jaw 
increased  in  length.  Erdheim  considered  these  tro- 
phic disturbances  an  absolute  constant  symptom  of 
tetany,  due  to  a  lack  of  calcium  deposit  in  the  grow- 
ing tissue.  In  addition  cataract  formation  was  ob- 
served in  the  rat. 

If  in  Erdheim's  animals  one-half  a  parathyroid 
was  left  behind,  no  tetany  at  all,  or  only  very  mild 
tetany,  appeared.  In  eight  cases  only  one  parathy- 
roid was  removed,  and  in  a  third  of  these  cases  there 


294  PARATHYROID    GLANDS 

were  seen  only  slight  indications  of  tetany.  In 
eight  rats  a  part  of  the  thyroid  was  removed  without 
injury  to  the  parathyroids  and  in  these  cases  no  sign 
of  tetany  or  of  cachexia  appeared.  This  work  of 
Erdheim's,  in  addition  to  proving  conclusively  the 
tetany  parathyropriva,  is  especially  significant  in 
calling  attention  to  the  trophic  disturbance  that 
may  occur  as  the  result  of  a  partial  loss  of  parathy- 
roid tissue. 

Alquier  has  observed  the  classic  results  following 
parathyroidectomy  in  a  considerable  number  of 
dogs,  the  symptoms  appearing  from  three  to  five 
days  after  complete  ablation  of  the  parathyroid 
glands.  This  author  calls  attention  to  the  care  that 
must  be  used  in  speaking  of  hypertrophy  of  the  para- 
thyroids, as  he  finds  great  variation  in  size  under 
normal  conditions  (some  authors  have  stated  that 
if  two  or  three  of  the  glands  are  removed  the  ones 
left  behind  undergo  hypertrophy).  Alquier  states 
that  he  attempted  to  produce  hypertrophy,  and  has 
studied  histologically  glands  left  behind  from  several 
days  up  to  six  months,  after  a  part  of  the  glands  have 
been  removed,  and  he  is  unable  to  state  with  cer- 
tainty that  any  hypertrophy  takes  place. 

Hagenbach  found  that  in  the  cat  it  was  possible 
to  extirpate  the  thyroid  plus  the  inner  parathyroids 
and  leave  the  outer.  When  this  was  done  the  para- 
thyroids left  behind  protected  the  animal  from  tet- 
any. Later  removal  of  the  remaining  parathyroids 
was  followed  by  pronounced  tetany.  This  author 
found  that  the  parathyroids  did  not  act  vicariously 
for  the  thyroid,  as  a  typical  cachexia  thyropriva 
developed  after  the  first  operation.     Hagenbach  in- 


POSTOPERATIVE    TETANY  295 

sists  that  functionally,  as  well  as  anatomically  and 
embryologically,  the  thyroid  and '  parathyroid  are 
separate  organs. 

Frommer's  experiments  have  confirmed  the  work 
of  other  investigators.  These  will  be  referred  to  in 
more  detail  later  on.  Segale  has  also  published  the 
results  of  much  experimental  research  on  these  bodies 
and  discusses  these  results  from  a  metabolic  stand- 
point. This  author  states  that  tetany,  although  of 
frequent  development  after  parathyroidectomy,  is 
not  a  fundamental  symptom.  After  parathyroid- 
ectomy' such  profound  disturbance  of  metabolism 
occurs  that  all  efforts  on  the  part  of  the  organism 
to  repair  it  are  absolutely  ineffectual.  He  empha- 
sizes the  importance  of  a  cachexia  strumipriva  due 
to  the  removal  of  the  parathyroid  glands. 

Pfeiffer  and  Mayer  have  also  studied  extensively 
post  operative  tetany  in  a  number  of  animals.  In 
twenty-nine  dogs  it  was  found  that  the  full-grown 
animal  developed  tetany  on  the  average  in  forty- 
three  hours  after  removal  of  the  parathyroid  glands. 
The  longest  latent  period  in  the  adult  dog  was  sixty- 
three  hours,  the  shortest  twenty-eight  hours.  In 
four  "goitre"  dogs  the  latent  period  was  somewhat 
shorter,  symptoms  appearing  as  early  as  sixteen 
hours  after  the  operation.  In  puppies  the  latent 
period  was  prolonged  to  an  average  of  sixty-nine 
hours,  and  the  animal  died  on  the  average  in  a  hun- 
dred and  ten  hours  after  the  operation.  These 
authors  also  operated  on  twenty-four  rats,  removing 
the  parathyroid  on  one  side  in  six  cases,  and  on  both 
sides  in  eighteen  cases  and  observed  chronic  and 
acute  forms  of  tetany  similar  to  those  described  by 


296  PARATHYROID    GLANDS 

Erdheim.  In  addition,  the  parathyroid  glands  were 
removed  from  sixty-eight  mice,  on  both  sides  in 
sixty-three,  on  one  side  in  five.  The  latter  showed 
no  notable  symptoms,  but  thirteen  of  the  former 
developed  the  typical  tetanic  symptom  complex  and 
death. 

Iselin  has  extirpated  the  parathyroid  glands  in 
young  rats  (five  to  twelve  weeks  old).  Seven  of 
these  animals  after  excision  of  the  parathyroids  de- 
veloped acute  tetany  and  death  within  two  days, 
showing  that  the  young  rats  are  much  more  suscept- 
ible to  this  injury  than  the  full  grown  animals. 
Still  more  susceptible  are  young  rats  born  from 
parathyroidectomized  parents.  These  animals  sur- 
vived operation  usually  only  four  hours,  and  died  in 
epileptiform  fulminating  tetany.  This  work  is  sig- 
nificant in  regard  to  its  bearing  on  children's  tetany. 

A  second  article  of  this  same  author  has  to  do 
with  the  body  development  of  the  young  rats  which 
have  survived  partial  parathyroidectomy.  In  some 
of  these  animals  a  chronic  form  of  tetany  developed 
which  showed  itself  through  apathy,  trembling  and 
continued  moderate  paralysis.  Later  nutritional 
disturbances,  fracture  of  the  teeth,  the  result  of 
alveolar  periostitis,  and  fistula  formation  appeared. 
Moreover,  these  animals  acquired  a  roughing  of  the 
fur  and  suffered  loss  in  the  .whole  body  development. 

Berkeley  and  Beebe  have  obtained  the  following 
results,  which  are  too  positive  to  need  discussion 
"The  entire  thyroidparathyroid  apparatus  has  been 
removed,  a  complete  thyroparathyroidectomy,  with 
the  result  that  the  animals  have  almost  invariably 
developed  symptoms  of  tetany  in  twelve  to  forty- 


POSTOPERATIVE    TETANY 


297 


eight  hours.  In  two  cases,  after  what  was  supposed 
to  be  the  complete  operation,  there  was  no  develop- 
ment of  symptoms  and  the  animals  were  kept  in 
one  instance  for  six  weeks,  and  in  the  other  for  some 
months  without  symptoms.  Probably  an  accessory 
parathyroid  not  removed  was  responsible  for  the 
nondevelopment  of  symptoms  in  these  cases,  al- 
though no  such  gland  was  found  at  the  autopsy. 
Thirty-four  dogs  were  operated  upon  in  this  group." 


i 

/}>                           ,'.?       ,?■       '     '" 

'    %*!  ; 

...  a%  >^  '-  &  p 

■. 

*        !S?       &  G 

■-1 

""    ^»    S  i_           ''5: 

...Jjg 

iP 

Fig.  71.  Parathyroid  glandule  sixteen  days  after  mass  ligation 
showing  fusion  of  masses  of  degenerated  parathyroid  epithelium. 
(Thompson  and  Leighton.) 

A  second  group  of  sixteen  animals  having  a  com- 
plete thyroparathyroidectomy  were  fed  or  inocu- 
lated with  thyroid  proteids,  in  order  to  determine 
whether  provision  of  thyroid  function  would  modify 
the  development  of  symptoms.  Even  the  hypo- 
dermic injection  daily  of  the  extract  of  two  normal 
dog's  thyroids  had  no  effect  in  retarding  the  develop- 
ment of  symptoms. 


298  PARATHYROID    GLANDS 

A  third  group  of  eighteen  animals  was  submitted 
to  operation  by  resection  of  a  portion  of  the  glands 
(thyroid  and  parathyroid  combined) ;  in  one  set  the 
anterior  one-half,  in  the  other  set  the  posterior  one- 
half.  In  resecting  the  anterior  one-half  of  the  gland, 
careful  search  was  always  made  for  the  parathyroid 
on  the  external  surface  of  the  thyroid,  and  care  was 
exercised  to  make  the  dividing  line  posterior  to  this 
glandule,  so  that  in  a  successful  removal  of  the  an- 
terior one-half  all  the  parathyroid  tissue  would  be 
removed  .and  yet  an  amount  of  thyroid  tissue  suffi- 
cient to  provide  for  the  physiological  need  of  the  ani- 
mal would  remain  in  a  normal  functional  condition. 
In  six  out  of  eight  cases  in  which  four  parathyroids 
were  seen  at  the  operation  and  removed  with  the 
anterior  half,  the  characteristic  symptoms  of  tetany 
developed  in  the  usual  time.  Subsequent  removal 
and  section  of  the  thyroid  tissue  remaining  showed 
it  to  be  in  a  physiological  condition.  In  those  cases 
in  which  the  posterior  half  was  removed,  the  divid- 
ing line  being  posterior  to  the  external  parathyroid, 
no  symptoms  were  observed. 

In  a  fourth  group  of  nine  animals  an  attempt  was 
made  to  destroy  the  parathyroids  with  the  actual 
cautery,  with  a  minimal  amount  of  injury  to  the  thy- 
roid. In  four  of  these  animals  four  parathyroids 
were  found  and  cauterized  and  in  these  the  operation 
was  followed  by  the  characteristic  symptoms  of 
tetany.  The  cautery  caused  only  a  small  amount  of 
injury  to  the  thyroid.  Microscopic  section  showed  no 
pathological  condition  of  the  latter  gland  and  its 
blood  supply  was  not  impaired,  so  that  there  can  be 
no  doubt  that  it  was  capable  of  functioning  in  these 


POSTOPERATIVE    TETANY  299 

cases,  but  the  symptoms  of  tetany  came  on  promptly 
and  were  quite  as  characteristic  in  this  group  as  in 
the  others  having  a  more  complete  operation. 

Thompson,  Leighton  and  Swarts,  in  connection 
with  their  work  on  ligation  of  the  parathyroid  artery 
referred  to  in  the  first  chapter,  have  shown  that  a 
single  parathyroid  glandule  is  sufficient  to  maintain 
life  in  a  dog,  but  when  this  is  removed  the  animal 
quickly  dies  in  tetany. 

These  authors  selected  dogs  in  which  four  nor- 
mally situated  parathyroids  could*  be  found  and  at 
their  first  operation  three  parathyroids  were  excised 
and  one  glandule  (with  its  artery  ligated),  left  in 
place.  Following  such  operation  no  symptoms,  save 
in  a  few  instances  slight  transient  tetany,  occurred, 
When  the  sustaining  glandule  was  excised,  however, 
the  dog  died  in  tetany.  In  three  dogs  removal  of 
the  fourth  glandule  did  not  result  in  tetany  and 
autopsy  showed  extra  parathyroids  in  these  latter 
instances;  so  that  not  infrequently  it  may  happen 
that  four  superficial  parathyroids  may  be  excised 
in  this  animal  and  extra  glandules  (usually  intra- 
thyroidal)  protect  the  animal  from  death.  As  long 
as  a  single  glandule  remains  the  animal  does  not  ex- 
hibit tetany.  When  this  last  glandule  is  removed 
the  animal  dies  in  tetany. 

EXPERIMENTS    OPPOSED    TO    TETANY. 

In  consideration  of  the  vast  amount  of  proof  that 
has  been  brought  forward  by  so  many  skilled  investi- 
gators in  favor  of  postoperative  tetany  as  a  result 
of  the  removal  of  the  parathyroid  glands,  it  seems 


300  PARATHYROID    GLANDS 

hardly  necessary  to  quote  the  few  articles  that  have 
appeared  from  time  to  time  in  opposition  to  this 
theory.  That  doubt  should  arise,  however,  is  quite 
natural  from  the  small  size  of  the  parathyroids  and 
the  seeming  inconsistency  that  such  little  organs 
could  be  of  such  vital  importance.  As  Erdheim 
says:  "Between  the  small  size  of  the  parathyroid 
glands  and  the  severe,  often- fatal  result  of  their  re- 
moval there  is  such  a  striking  contrast,  that  the 
function  of  these  bodies  strikes  us  as  something 
marvelous,  and  we  are  apt  to  maintain  a  skeptical 
attitude  thereto." 

Blumenreich  and  Jacoby  have  denied  the  influ- 
ence of  the  parathyroids  in  the  production  of  the 
tetanic  symptoms  described  by  other  authors.  A 
careful  examination  of  their  work  fails  to  show  that 
they  removed  all  the  parathyroid  tissue  in  their  ex- 
periments, and  we  know  that  a  single  parathyroid 
left  intact  is  sufficient  to  prevent  the  development 
of  tetany.  In  twelve  rabbits  these  authors  removed 
the  thyroid  and  two  parathyroids,  in  five  animals 
the  thyroid  and  one  parathyroid,  and  in  four  only 
the  thyroid.  They  found  no  difference  between  re- 
moval of  the  thyroid  alone  and  the  thyroid  with 
one  or  two  parathyroids. 

Blum  has  declared  that  in  his  opinion  the  para- 
thyroids are  nothing  more  than  embryonic  thyroid 
possessing  no  particular  function  in  the  body.  He 
rests  this  assumption,  however,  on  the  work  of  Kishi 
which  has  been  severely  attacked  by  Erdheim  as 
showing  sovereign  ignorance  of  the  work  of  previous 
investigators  on  the  embryology  and  anatomy  of 
these  glands     Kishi  seems  to  be  absolutely  unaware 


POSTOPERATIVE    TETANY  301 

of  the  presence  of  the  internal  parathyroids  in  cats 
and  dogs  and  his  work,  therefore,  is  practically  with- 
out value. 

As  a  further  proof  of  his  assumption  Blum  offers 
the  results  of  his  experiments  on  a  number  of  dogs 
from  which  the  greater  part  of  the  thyroid  and  (pre- 
sumably) the  parathyroids  were  removed  without 
obtaining  tetany.  However,  in  several  of  these  dogs 
on  which  a  second  operation  was  performed  for  the 
extirpation  of  the  tissue  left  behind  death  in  tetany 
was  obtained.  Blum  describes  changes  in  the  thy- 
roid that  have  been  left  behind  consisting  in  an  ex- 
traordinary cell  increase  which  caused  them  to  ap- 
pear similar  to  parathyroid  in  their  structure  and 
he  thinks  that  the  small  thyroid  rests  were  able  to 
perform  the  duty  of  both  thyroid  and  parathyroid. 
In  this  conclusion  he  has  few  supporters  and  his 
technic  may  be  criticised  as  not  definitely  proving 
the  removal  of  all  parathyroid  tissue. 

Bayon  has,  incidentally  in  the  course  of  other  work, 
made  the  observation  that  thyro-parathyroidectomy 
is  not  fatal  for  the  rabbit.  Apparently  this  author 
has  not  taken  into  consideration  the  extrathyroidal 
parathyroids  in  the  rabbit  and  in  his  experiments 
failed  to  remove  two  parathyroid  glands. 

Caro  thinks  that  the  accidents  observed  by  pre- 
vious authors  cannot  be  separated  into  those  due 
to  loss  of  thyroid  and  those  due  to  loss  of  parathyroid. 
His  experiments  on  dogs  led  him  to  conclude  that 
a  very  small  amount  of  thyroid  protected  the  animal 
from  tetany,  but  when  these  remnants  were  removed 
death  of  the  animal  in  tetany  resulted.  These  thy- 
roid remnants  he  describes  as  being  entirely  free  from 


302  PARATHYROID    GLANDS 

parathyroid  tissue.  This  author  attacks  especially 
the  work  of  Erdheim,  but  as  Schirmer,  who  has  criti- 
cally reviewed  both  the  results,  states:  "If  one  com- 
pares the  large  amount  of  material  of  Erdheim 
worked  out  with  such  rare  industry,  and  such  min- 
ute exactness  in  its  technical  and  histological  detail, 
with  the  work  of  Caro's  which  lacks  weight  in  many 
essential  points  and  leaves  important  details  to  in- 
complete footnotes,  one  will  be  convinced  that  the 
attack  of  Caro  will  have  little  effect  in  weakening 
the  results  of  Erdheim's  extensively  compiled  evi- 
dence." 

Vincent  and  Jolly  have  also  reached  results  that 
differ  considerably  from  those  of  previous  investi- 
gators and  are  not  so  easy  of  criticism  since  the  work 
appears  to  have  been  carried  out  with  much  care 
and  exact  knowledge  of  anatomy  on  a  large  number 
of  animals  of  many  different  species. '  These  inves- 
tigators did  obtain  tetany  and  death  in  a  number 
of  instances  after  parathyroid  removal,  but  not  with 
the  same  uniformity  as  did  the  other  investigators 
that  we  have  previously  quoted.  These  authors  con- 
clude that  neither  the  thyroid  nor  parathyroids  are 
essential  to  life  since  it  is  frequently  possible  to  re- 
move either  or  both  without  causing  death.  Out  of 
fifteen  cats  on  which  the  complete  operation  was 
performed  ten  died  with  the  usual  "nervous  symp- 
toms." Of  the  five  surviving  animals  three  showed 
grave  "nervous  symptoms."  One  cat  showed  no 
symptoms,  and  a  young  cat  ceased  for  a  time  to 
grow  but  otherwise  remained  normal.  These  authors 
used  the  term  "nervous  symptoms"  rather  than 
"tetany."     These  symptoms  are  described  as  a  curi- 


PLATE  XXXVIII 


P.  T.       PARATHYROID    GLANDULES.       TWO    INFERIOR    GLANDULES    FOUND    ON 
THE  LEFT;    THE  INFERIOR  ON   THE  RIGHT   SIDE   NOT  FOUND. 


POSTOPERATIVE    TETANY  303 

ous  "paw-shaking"  and  some  malaise.  This  is  fol- 
lowed in  rapid  succession  by  "tremors,"  stiffness  of 
gait  and  convulsions.  "Even  in  a  quiescent  state, 
the  forelegs  tend  to  be  flexed,  while  the  hind  legs  are 
extended,  a  position  exaggerated  during  the  con- 
vulsions." 

Out  of  five  dogs  operated  on  by  these  authors  typi- 
cal tetanic  symptoms  were  produced  in  all  save  one 
Although  these  authors  state  that  in  this  case  there 
cannot  be  the  slightest  doubt  that  thyroids  and  para- 
thyroids were  completely  removed,  the  not  infre- 
quent finding  of  accessory  parathyroids,  at  times 
considerably  removed  from  their  normal  situation, 
as  we  have  previoulsy  chronicled,  makes  it  impossible 
for  us  to  accept  such  a  statement  as  absolute.  In 
four  foxes  from  which  thyroids  and  parathyroids 
were  removed  all  died  in  severe  tetany,  the  symp- 
toms appearing  with  remarkable  rapidity.  In  seven 
monkeys  on  which  the  same  experiment  was  per- 
formed none  died  and  in  only  two  were  tetanic 
symptoms  observed.  Their  experiments  on  rats 
while  negative  were  too  few  to  admit  comparison 
with  the  extensive  work  of  Erdheim  on  this  animal. 
Finally,  following  the  complete  operation  upon  four 
guinea  pigs,  no  symptoms  of  any  kind  were  observed. 
As  the  authors  themselves  state  the  extreme  vari- 
ability in  the  anatomy  of  the  parathyroids  in  this 
latter  animal  has  rendered  their  experiments  rather 
unsatisfactory. 

In  a  later  article  these  authors  continued  their 
experiments  with  results  similar  to  those  just  re- 
corded. One  monkey  died  in  convulsions  on  the  day 
following  the  operation,  but  the  authors  state  that 


304  PARATHYROID    GLANDS 

in  this  case  the  recurrent  laryngeal  nerve  on  one  side 
was  included  in  a  ligature.  Of  two  prairie  wolves 
one  developed  a  convulsive  attack  with  typical  rapid 
respiration  which  lasted  for  two  days  but  subsided 
and  death  did  not  occur  until  thirty-eight  days  after 
the  operation.  The  other  animal  showed  no  symp- 
toms. Two  badgers  exhibited  no  symptoms  after 
"complete ' '  operation . 

A  careful  analysis  of  this  work  fails  to  show  wherein 
the  authors  are  justified  in  their  somewhat  sweeping 
assertion  that  neither  thyroids  nor  parathyroids  are 
essential  to  life.  While  their  results  have  not  been 
so  striking  as  those  of  some  of  the  previous  investi- 
gators, still  it  will  be  noted  that  a  great  many  of 
their  experiments  show  the  same  fatal  outcome  that 
we  have  been  led  to  expect  following  the  removal 
of  the  parathyroid  glands.  Where  such  outcome 
was  not  forthcoming  it  was  usually  in  animals  in 
which  the  distribution  of  the  parathyroid  tissue  has 
not  been  carefully  worked  out  and  we  can  only  as- 
sume in  such  instances  that  the  parathyroid  glands 
were  not  removed  with  absolute  completeness.  In 
fact,  since  the  publication  of  this  work  Harvier  and 
Morel  have  shown  that  in  the  cat  accessory  para- 
thyroids are  to  be  found  in  the  thymus  in  fifty  per 
cent,  of  cases. 

While  it  is  impossible  to  note  the  opinions  of  all 
authors  who  have  thrown  their  argument  to  either 
one  side  or  the  other  of  this  question,  we  may  note 
that  Munk  has  laid  considerable  stress  dn  the  cases 
of  survival  after  the  removal  of  the  thyroid  and 
parathyroid  glands  and  he  states  that  in  his  opinion 
the  tetany  observed  in  such  cases  is  the  result  of 


POSTOPERATIVE    TETANY  305 

nerve  injury;  a  statement  that  is  disproven  by  the 
numerous  experiments  in  which  a  single  parathyroid 
left  behind  will  protect  the  animal  from  tetany  de- 
spite extensive  trauma. 

CHRONIC    DISTURBANCES    DUE     TO     PARTIAL     LOSS    OF 
THE   PARATHYROID   GLANDULES. 

In  the  emphasis  that  has  been  put  upon  the  tetany 
following  the  complete  loss  of  the  parathyroid  glands, 
nutritional  disturbance  following  parathyroid  oper- 
ations has  been  given  scant  attention,  although 
trophic  disturbance  following  interference  with, 
but  not  complete  loss  of,  these  glandules  has  been 
casuistically  noted  since  the  time  of  Gley,  who  stated 
that  in  both  dogs  and  rabbits  he  had  sometimes 
observed  only  nutritive  disturbances  after  parathy- 
roidectomy. 

Vassale  and  Generali  noted  that  one  of  their 
parathyroidectomized  cats  survived  for  two  months 
with  symptoms  of  chronic  cachexia.  Pineles  de- 
scribed trophic  disturbances  in  the  ape  consisting  of 
falling  of  the  hair,  anemia,  skin  ulcers  and  oedema 
of  the  upper  eyelids  (in  these  cases  thyroid  as  well 
as  parathyroids  was  removed).  Also  in  cats  fol- 
lowing similar  operation  apathy  and  trophic  dis- 
turbances were  observed  by  this  author.  Walbaum 
recounted  cachexia  appearing  in  rabbits  with  nutri- 
tional disturbances,  especially  roughening  of  their 
coats,  in  the  course  of  his  experiments.  Segale  in- 
sisted that  we  must  regard  cachexia  as  depending 
especially  on  the  removal  of  the  parathyroid  glands. 
MacCallum  has  observed  cachexia  as  a  result  of  para- 
thyroid removal  in  certain  of  his  dogs,  and  in  three 


306  PARATHYROID    GLANDS 

sheep  he  reported  that  a  marked  emaciation  and 
apathy  followed  parathyroid  removal.  Vincent  and 
Jolly  noted  cachectic  symptoms  in  a  number  of 
their  animals  operated  on. 

Pinto  found  that  while  a  total  ischemia  of  the 
thyro-parathyroid  apparatus  was  followed  by  tetany 
in  from  sixteen  to  thirty-one  hours,  if  it  was  longer 
continued,  symptoms  of  tetany  and  cachexia  or  only 
pure  symptoms  of  cachexia  were  observed. 

The  work  of  Erdheim,  who  obtained  chronic  nutri- 
tional disturbances,  especially  enamel  defects  lead- 
ing to  fracture  of  the  teeth,  in  parathyroidectomized 
rats,  is  especially  significant  along  this  line.  We 
have  already  quoted  his  results  at  length. 

That  disturbances  of  a  trophic  nature  may  occur 
in  connection  with  partial  loss  of  parathyroid  tissue, 
then,  is  a  well  established  fact,  and  its  occurrence, 
apart  from  tetany,  has  been  especially  studied  by 
Thompson  and  Leighton,  in  twenty  dogs.  In  these 
animals  the  parathyroids  were  gradually  destroyed 
by  mass  ligation  instead  of  excising  them  as  had 
been  done  by  previous  experimenters.  These  authors 
state:  "Following  the  ligation  of  the  parathyroid 
glandules  in  the  dog  one  of  two  things  may  happen : 
(a)  Functioning  islets  of  gland  tissue  may  persist, 
keeping  the  dog  alive  for  a  considerable  length  of 
time ;  (b)  The  glandules  may  eventually  be  replaced 
by  dense  fibrous  tissue  and  the  dog  die.  In  either 
event  a  train  of  symptoms  of  a  trophic  nature  arises, 
entirely  different  in  character  from  the  severe  acute 
tetanic  manifestations  that  follow  complete  para- 
thyroid excision  in  these  animals."  This  brings  two 
facts    into    prominence    that    are    worthy    of    note. 


POSTOPERATIVE    TETANY 


307 


First,  which  is  important  for  practical  surgery,  that 
ligation  of  the  parathyroids,  whereby  they  are  left 
in  situ  with  their  usual  blood  supply  destroyed,  does 
not  always  destroy  the  glandules  and  is  not  the  same 
thing  as  excision.  Second,  that  by  this  ligation  of 
the  parathyroids,  disturbances  of  nutrition,  which 
may  ultimately  end  in  death,  can  be  brought  about 
without  producing  any  tetanic  symptoms  whatso- 


Fig.  72.  Complete  destruction  of  parathyroid  by  mass  ligation, 
forty-eight  days.  Death  in  cachexia  with  no  tetany  followed  this 
gradual  complete  destruction  of  parathyroid  tissue. 

ever,  although  the  death  can  be  definitely  proven 
to  be  due  to  loss  of  the  parathyroid  glands. 

In  these  experiments  the  glandules,  after  partial 
separation  from  thyroid  or  capsule  and  identification 
of  the  parathyroid  artery,  were  lifted  up  by  wide  rat- 
tooth  forceps,  which  were  crushed  into  the  under- 


308  PARATHYROID    GLANDS 

lying  thyroid  tissue,  and  a  strong  linen  ligature  passed 
around  the  whole  mass.  This  procedure  seemed  to 
approximate  the  conditions  of  accidental  injury  that 
might  occur  in  connection  with  thyroid  operations 
whereby  granulation  tissue  could  form  from  in- 
jured tissue  about  the  parathyroids. 

The  following  is  a  brief  summary  of  the  results  ob- 
tained in  these  dogs  where  chronic  death  with  nutri- 
tional disturbances  replaced  the  tetany  that  usually 
occurs  subsequent  to  loss  of  the  parathyroids: 

Operation:  ligation  of  two  parathyroids  on  right 
side.  Removal  of  thyroid  (with  parathyroids)  on 
left  side.  Dog  recovered  from  operation  and  showed 
no  symptoms  for  several  days.  On  fifth  day  ani- 
mal slept  a  good  deal  and  took  food  sparingly. 
On  the  sixth  day  dog  appeared  weak  and  refused 
food.  Died  on  the  seventh  day  very  quietly,  but 
with  the  development  of  a  slight  tremor  just  before 
death.  Microscopic  examination  of  the  ligated  para- 
thyroids showed  them  to  be  replaced  by  fibrous 
tissue. 

Operation:  ligation  of  two  parathyroids  on  right. 
Removal  of  thyroid  (with  parathyroids)  on  left. 
Dog  recovered  perfectly  from  the  operation  and 
lived  thirty-three  days.  During  this  time  it  pro- 
gressively lost  in  weight  and  strength.  The  animal 
lay  curled  up  in  his  cage  in  an  apathetic  condition, 
refused  food,  and  was  finally  found  dead.  At  autop- 
sy the  ligated  glandules  were  found  completely  re- 
placed by  fibrous  tissue. 

Operation:  five  parathyroids  found  (the  left  ex- 
ternal double)  and  all  ligated.  Despite  the  appar- 
ently complete  operation  the  dog  showed  no  acute 


POSTOPERATIVE    TETANY  309 

symptoms.  The  animal  lost  rapidly  in  weight,  how- 
ever, and  a  slight  conjunctivitis  developed.  Forty- 
four  days  after  first  operation  neck  was  again  opened 
and  a  large  (hypertrophic?)  parathyroid  found  on 
the  right  (evidently  analogous  to  the  double  glandule 
of  the  left  side)  that  had  escaped  at  the  first  opera- 
tion. This  was  ligated.  Ligatures  of  the  previous 
operation  in  place  and  only  connective  tissue  thick- 
ening to  be  seen  macroscopically  about  them.  Neck 
closed  up.  Dog  soon  began  to  show  marked  weak- 
ness, could  scarcely  stand  on  his  feet  a  few  days 
after  the  operation,  and  took  food  sparingly.  De- 
spite this  great  emaciation  and  weakness  the  dog 
remained  in  this  condition  for  eighteen  days,  getting 
toward  the  end  so  weak  it  was  difficult  to  tell  whether 
it  was  living  or  dead.  The  animal  lay  curled  up  and 
sleeping  for  days  without  change  of  position  and  with- 
out taking  food.     Finally  found  dead  in  this  position. 

The  conclusions  reached  as  a  result  of  this  work, 
are :  "Following  the  gradual  destruction  of  the  para- 
thyroid glandules  in  the  dog  a  train  of  symptoms 
arises  different  from  those  obtained  by  parathyroid 
excision.  After  ligation  of  all  parathyroid  tissue  the 
dog  passes  the  time  limits  of  tetanic  death  that 
occurs  after  excision  of  the  glandules,  practically 
without  symptoms.  Gradually,  however,  chronic 
symptoms,  trophic  in  nature,  arise.  These  consist 
in  gradual  but  progressive  loss  of  weight  and  strength, 
greatly  diminished  resistance  to  infection,  and  a  final 
stuporous  condition  ending  in  death  without  tetany. 

These  nutritional  disturbances  are  as  marked  when 
the  thyroid  is  not  injured  as  they  are  when  the  thy- 
roid is  removed  on  one  side. 


310  PARATHYROID    GLANDS 

These  observations  should  lead  to  a  modified  con- 
sideration of  diseases  that  are  supposed  to  be  hypo- 
parathyroid  in  origin,  and  suggest  a  revision  of  the 
epitomized  statement  of  Jeandelize,  "that  insuffi- 
ciency of  the  thyroids  causes  nutritional  disturbances, 
while  insufficiency  of  the  parathyroids  causes 
acute  convulsive  troubles."  The  preferable  state- 
ment regarding  the  parathyroids  as  the  result  of 
this  work  is,  that  while  sudden  loss  of  the  parathy- 
roids results  in  acute  convulsive  troubles,  slow  de- 
struction of  the  same  gives  rise  to  chronic  nutritional 
disturbances,  which  eventually  end  in  death  without 
tetanic  manifestation. 

The  recent  observations  of  Iselin  on  the  disturb- 
ances of  nutrition,  and  even  the  prevention  of  devel- 
opment, in  young  rats  following  partial  parathy- 
roidectomy make  necessary  the  consideration  of 
these  bodies  as  having  an  influence  on  retarded  body 
development. 


CHAPTER  XVIII. 


SURGICAL  ACCIDENTS  IN  MAN  DUE  TO 

REMOVAL  OF  THE  PARATHYROID 

GLANDULES. 


Let  us  now  return  to  the  more  practical  side  of 
this  question,  namely:  what  role  do  the  parathyroid 
glands  play  in  the  tetany  sometimes  observed  after 
operations  on  the  thyroid  gland  in  man  ?  Accidents 
following  such  operations,  to  which  we  have  already 
casually  referred,  have  fortunately  been  reduced 
to  a  minimum,  but  formerly  they  were  not  so  rare. 

Weiss,  in  1883,  was  able  to  collect  thirteen  cases 
of  postoperative  tetany  from  the  literature.  He 
maintained  that  the  symptoms  were  the  result  of 
injury  to  the  blood  vessels  and  their  accompanying 
sympathetics.  Because  of  the  injury  to  these  an 
irritation  was  set  up  in  the  anterior  horn  of  the  spinal 
cord  which  expressed  itself  in  the  tetanic  symptoms. 
This  theory,  with  certain  modifications,  had  some 
supporters  until  the  work  of  Reverdin  and  of  Kocher 
appeared. 

Reverdin  and  Kocher  demonstrated  that  the  symp- 
toms were  a  result  of  the  goitre  removal  and  that  one 
was  able  to  escape  tetany  and  cachexia  strumipriva 
by  leaving  in  place  a  part  of  the  thyroid  gland 
The  part  naturally  left  behind  was  the  posterior  bor- 
der and  therefore  by  this  method  the  parathyroid 
glands  were  not  sacrificed.     The  importance  of  this 


312  PARATHYROID    GLANDS 

observation  may  be  emphasized  by  the  fact  that 
before  that  time  such  observations  as  the  ten  cases 
of  tetany  in  thirty-eight  thyroidectomies  by  Billroth, 
three  cases  out  of  seventeen  operations  by  Reverdin, 
and  four  cases  out  of  seven  by  Mikulicz  were  re- 
ported. 

It  was  no.  longer  ago  than  the  early  eighties  that 
such  reports  as  the  preceding,  and  such  graphic 
descriptions  as  follows,  might  be  read  as  the  result 
of  thyroid  operations:  "Some  days  after  thyroid- 
ectomy, ordinarily  on  the  third  or  sixth  day,  some- 
times a  little  earlier  or  later"  (at  the  end  of  four 
months  in  a  case  of  Kocher's),  "the  patient  was 
seized  with  convulsions  of  the  extremities,  more  often 
the  superior,  which  were  sometimes  preceded  by 
tingling  in  the  fingers  "or  twitching  of  the  muscles. 
Usually  chronic  contractions  appeared,  the  hands 
closed  with  such  violence  that  the  nails  often  pene- 
trated the  skin.  The  limbs  were  sometimes  con- 
tracted so  that  it  seemed  they  were  going  to  break; 
even  the  diaphragm  was  at  times  involved." 

Kocher  has  noted  epileptiform  crises  of  short 
duration,  followed  by  loss  of  consciousness.  Crises 
renewed  themselves  as  often  as  fifteen  times  a  day. 
Sometimes  the  tetany  ceased  rapidly  after  a  duration 
of  eight  to  fifteen  days,  or  at  times  it  was  prolonged 
for  months  and  years  with  remissions.  Death  in 
these  cases  seemed  to  result  from  a  dyspnoea  which 
was  not  allayed  by  tracheotomy. 

It  was  sometime  before  the  fact  was  brought  to 
light  that  these  postoperative  tetanies  in  man  were 
due  not  to  the  loss  of  the  thyroid  gland,  but  to  the 
loss  of  the  parathyroid  glands.     And  the  acceptance 


SURGICAL  ACCIDENTS  IN   .MAX  313 

of  the  functional  significance  of  the  parathyroids 
has  been  brought  about  only  by  a  great  amount  of 
work;  to  the  finishing  touches  of  which  we  are  es- 
pecially ■indebted  to  the  Vienna  School.  Biedl, 
Eiselsberg,  Erdheim,  and  Pineles  may  be  mentioned 
among  those  who  have  given  special  attention  to 
this  question. 

Among  the  first  to  study  the  relation  of  the  para- 
thyroids to  goitre  was  Benjamins,  who  examined  the 
parathyroids  in  twenty  cases  of  goitre  which  had  been 
dealt  with  surgically.  While  he  found  no  histologic 
changes  in  the  parathyroids,  as  we  have  previously 
noted,  nevertheless  he  brought  forward  certain  clini- 
cal observations  relating  to  the  removal  of  these 
glands.  Out  of  nine  cases  in  which  clinical  histories 
were  obtained,  parathyroids  were  found  in  five  that 
had  been  removed  with  the  thyroid;  in  the  other 
four  cases  the  parathyroids  had  not  been  removed.' 
Of  the  former  five  cases  only  one  failed  to  develop  tet- 
any ;  of  the  latter  there  was  no  tetany  in  any  of  the 
cases. 

This  was  in  1902,  and  it  was  about  this  time  that 
Jeandelize  made  his  significant  statement  that  in- 
sufficiency of  the  thyroid  causes  chronic  nutritional 
disturbances,,  while  insufficiency  of  the  parathyroids 
causes  acute  convulsive  disturbances.  This  state- 
ment was  at  once  upheld  by  Biedl,  Pineles  and 
Kocher. 

Pineles  collected  from  the  literature  sixteen  cases 
of  tetany  following  partial  parathyroidectomy  and 
with  a  clear  idea  of  the  relationship  of  the  parathy- 
roid glands  to  postoperative  tetany  in  mind,  this 
author  has  given  us  a  very  complete  discussion  of 


314 


PARATHYROID    GLANDS 


this  question.  He  discusses  separately  the  total  and 
the  partial  thyroidectomies,  and  has  collected  fifteen 
cases  in  which  partial  removal  of  the  thyroid  gland 
was  followed  by  more  or  less  severe  symptoms  of 
tetany.     These  cases  are  tabulated  as  follows: 


Observer 


Szuman... 
Hoffman.. 
Turetta. . . 

Czyhlarz. . 
Eiselsberg . 

Westphal. 

Eiselsberg 

Eiselsberg 
Eiselsberg 
Meinert. . . 


Kummer... 
Eiselsberg. 
Schilling. .  . 

Bruns 

Eiselsberg  . 


Operation 


Lateral  thyroid  lobes .... 

Both  thyroid  lobes 

Both  thyroid  lobes 

Both  thyroid  lobes 

Both  thyroid  lobes 

Sparing  of  isthmus  and 
upper  pole 

Sparing  of  isthmus  and 
one  upper  pole 

Sparing  one  upper  pole.  .  . 

Sparing  one  upper  pole.  .  . 

Right  lateral  lobe 

Right  lateral  lobe 

Right  lateral  lobe 

L.  lateral  and  middle 
lobes 

Nodules  and  cysts  extir- 
pated  

Tumor 


Tetany 

appeared  after 

Operation 


Fourth  day. 
Third  day... 
Fifth  day.... 

Third  day... 
Third  day... 


Second  day. 

Second  day. 
Fourth  day. 
Fourth  day. 
Fourth  day. 


Third  day 

Four  months.  . 
Fourteen  days . 

Second  day.  .  . 


Tetany — Con- 
tinued 


Four  months. 
Fifteen  days. 
Died  on  eighth 
day. 

Death  on  six- 
teenth day. 

Six  months. 

Seven  days. 

Ten  days. 

One  year. 

Fourteen  days 
and  recur- 
rence with 
pregnancy. 

One  year. 

Nine  days. 

Eight  days. 
Death  on  18th 

day. 
Mild  facialis 

tetany. 


It  is  to  be  noted  that  in  the  first  six  cases  only  the 
isthmus  of  the  thyroid  was  left  behind.  The  lateral 
lobes  of  the  gland  on  both  sides  were  removed  where- 
by a  good  opportunity  for  removal  of  parathyroids 
was  offered.  Likewise  in  the  second  group  where 
the  isthmus  and  the  uppermost  part  of  a  thyroid 
lobe  were  spared  parts  were  unfortunately  selected 
that  were  not  in  relation  with  the  parathyroid  glands 


SURGICAL  ACCIDENTS  IN  MAN  315 

and  no  protection  was  offered  these  bodies  by  leaving 
such  portions  of  the  thyroid  behind.  Why  tetany 
should  arise  in  the  last  three  cases  where  a  lateral 
thyroid  lobe  was  spared  in  one  side  is  not  easily 
accounted  for,  but  an  examination  of  the  detailed 
reports  of  these  cases  shows  that  in  the  first  the  oper- 
ation was  undertaken  during  the  course  of  preg- 
nancy; in  the  second  the  thyroid  lobe  left  behind  is 
described  as  very  small ;  and  in  the  third  only  a  mild 
tetany  was  present  which  cleared  up  completely  in 
nine  days. 

From  these  observations  Pineles  concluded  that 
it  is  the  same  in  man  as  in  animals,  that  when  the 
parathyroids  are  spared  no  tetanic  symptoms  follow 
a  thyroid  operation.  The  cases  developing  tetany 
are  those  in  which  such  parts  of  the  thyroid  only 
were  spared  as  did  not  protect  from  removal  of  the 
parathyroid  glands.  This  view  was  supported  by 
Escherich  who  clinically  confirmed  the  rarity  of 
tetany  following  operations,  in  which  loss  of  these 
glandules  was  more  carefully  guarded  against. 

Kocher  has  strongly  differentiated  between  the 
symptoms  arising  from  thyroid  insufficiency,  and 
those  the  result  of  parathyroid  insufficiency.  The 
latter  symptoms  he  classifies  as  an  intoxication, 
making  its  appearance  as  a  tetania  parathyropriva . 

Perhaps  the  most  practical  contribution  to  this 
important  question  is  the  work  of  Erdheim,  who 
examined  histologically  in  serial  sections  the  neck 
organs  in  three  cases  from  patients  dying  of  tetany 
after  partial  double  thyroidectomy.  In  all  three 
cases,  although  some  of  the  thyroid  had  been  left 
behind,    all   four   parathyroids    had   been    removed 


316  PARATHYROID    GLANDS 

(in  one  case  two  very  tiny  accessory  parathyroids 
were  present).  From  this  unequivocal  result  Erd- 
heim  concludes  that  it  is  the  plain  duty  for  the  sur- 
geon of  the  future  to  assure  himself  that  the  para- 
thyroid  glands   are    spared    in  thyroid  operations. 

The  rarity  of  tetany  today  following  such  opera- 
tions is  due  to  the  technical  methods  by  which  the 
thyroid  is  now  removed.  Especially  to  be  com- 
mended is  the  subcapsular  procedure  of  Dr.  C.  H. 
Mayo,  which  was  suggested  primarily  to  avoid  injury 
to  the  recurrent  laryngeal  nerve,  and  the  ultra  liga- 
tion of  the  thyroid  arteries  as  is  recommended  by 
Halsted.  So  it  has  come  about,  as  we  have  noted 
in  detail  in  the  first  chapter,  that  tetany  following 
thyroid  removal  has  been  reduced  to  less  than  one- 
half  of  one  per  cent  for  all  cases. 

In  discussing  the  paper  of  Erdheim,  Eiselsberg  re- 
ports that  up  to  1890  there  were  in  his  clinic  twelve 
cases  of  tetany  as  a  result  of  complete  thyroid  ex- 
tirpation. In  four  of  these  cases  the  patients  died 
with  violent  symptoms;  three  had  chronic  tetany 
which  kept  recurring,  and  one  recovered.  In  eighty 
partial  extirpations  there  were  only  two  cases  of 
tetany  and  those  were  not  severe.  Since  1890  he 
had  observed  only  one  case  of  deadly  tetany  but 
there  had  been  sixteen  light  tetanies  following  goitre 
operation. 

In  this  country  postoperative  tetany  is  less  fre- 
quently encountered.  Frazier  reports  the  result  of 
personal  inquiry  from  fifty-four  surgeons  represent- 
ing from  1,500  to  2,000  goitre  operations.  Only 
eight  cases  of  tetany  were  reported,  three  of  which 
were  fatal.     Of  the  remaining  five,  one  was  transi- 


SURGICAL  ACCIDENTS  IN  MAN  317 

tory,  and  one  was  described  as  a  slight  case.  C.  H. 
Mayo  had  had  but  one  slight  tetany  in  connection 
with  his  numerous  goitre  operations. 

Kocher  reports  that  in  his  last  1,000  goitre  opera- 
tions tetany  has  been  observed  only  five  times. 
Moreover,  these  five  cases  were  all  secondary  opera- 
tions where  firm  connective  tissue  adhesions  compli- 
cated the  operative  technic. 

Even  when  tetany  has  occurred  following  goitre 
operation  a  means  is  now  offered  for  its  control  by 
the  administration  of  parathyroid  gland  extracts, 
calcium  salts  and  transplantation;  the  details  of 
which  will  be  considered  in  a  later  chapter. 


CHAPTER  XIX. 


THE  RELATION  OF  THE  PARATHYROID 
GLANDS  TO  MEDICAL  TETANY. 


A  loss  of  parathyroid  function  was  first  suggested 
by  Jeandelize  as  the  cause  of  tetany  in  adults  and 
later  emphasized  by  Pineles,  who  grouped  together 
thyroid  tetany,  occupation  tetany,  tetany  of  child- 
birth, children 's  tetany,  and  gastric  tetany.  This  identi  - 
tyof  different  forms  of  tetany  was  accepted  by  Chvos- 
tek,  who  stated  that  for  all,  only  one  cause  could  be 
considered,  namely,  functional  diseases  of  the  para- 
thyroid glands. 

It  is  well  to  have  a  definite  subdivision  of  these 
various  tetanies  in  mind  for  purposes  of  discussion, 
and  the  following  grouping  of  Frankl-Hochwart  is 
perhaps  the  best.  This  author  divides  the  tetanies 
as  follows:  Tetany  following  or  accompanying  cer- 
tain infectious  diseases.  Tetany  in  cases  of  gastric 
dilatation  with  stagnation  of  the  stomach  contents. 
Tetany  in  infants  and  children.  Tetany  occurring  in 
connection  with  certain  trades  (Arbeiterstetanie) . 
Tetany  associated  with  osteomalacia,  and  rickets. 
Tetany  occurring  in  the  course  of  pregnancy  and 
lactation. 

In  all  these  tetanies  there  is  an  increased  excitabil- 
ity of  the  central  nervous  system  which  is  shown  by 
quantitative  tests  with  faradic  and  galvanic  currents, 


MEDICAL    TETANY 


319 


hypersusceptibility  of  the  facial  nerve  being  usually 
easily  demonstrable.  There  may  be  spasmodic  rigid- 
ity of  the  muscles,  sometimes  with  such  violent 
twitchings  as  to  constitute  an  epileptiform  convulsion. 


thymus 


M .  faff'fs-  er.  /909 


Fig.  73.  On  the  left,  masses  of  thymus  tissue  are  seen  in  con- 
nection with  the  parathyroid  glandules.  These  aberrant  thymus 
fragments  are  not  uncommon  in  infants  and  may  be  mistaken  for  the 
parathyroids  themselves". 

Fibrillary  tremors  of  the  tongue  and  rigidity  of  the 
jaws  may  be  present.  Quickening  of  the  pulse  and 
elevation  of  the  temperature  are  sometimes  observed. 


320  PARATHYROID    GLANDS 

Pineles  was  one  of  the  first  to  call  attention 
to  the  uniformity  of  symptoms  in  postoperative 
tetany  in  mam  and  animals  on  the  one  side,  and  in 
the  different  forms  of  idiopathic  tetany  on  the  other 
side.  This  uniformity,  according  to  Pineles,  points 
towards  a  specific  intoxication  common  alike  to  all 
these  various  tetanic  forms,  and  he  brings  forward 
as  the  causal  factor  in  these  conditions  insufficiency 
of  the  parathyroid  glands. 

Chvostek  has  accepted  the  view  of  Pineles  con- 
cerning the  general  identity  of  all  forms  of  tetany, 
the  cause  of  which  may  be  found  in  the  functional 
disturbances  of  the  parathyroid  glands  brought 
about  usually  by  disturbances  of  circulation  in  these 
organs.  The  typical  symptoms  can  arise  through 
a  special  poison  which  so  acts  that  a  specific  tetanic 
reaction  may  be  brought  about  in  a  susceptible  in- 
dividual by  an  injury,  which  in  another  person 
would  not  give  rise  to  tetany.  This  susceptibility 
to  tetany  may  be  congenital  or  acquired. 

Chvostek  also  believes  that  tetany,  just  like  goitre, 
is  epidemic  in  certain  localities  and  preponderates 
especially  at  certain  definite  seasons.  Tetany  is 
frequent,  for  instance,  in  Vienna  and  Heidelberg, 
while  it  is  rare  in  Paris,  although  some  years  ago  it 
was  common  in  that  place.  In  Vienna  tetany  is 
most  frequently  observed  in  the  months  of  March 
and  April,  occurring  most  frequently  in  shoemakers 
and  tailors.  Chvostek  states  that  there  is  a  definite 
antagonism  between  goitre  and  tetany;  tetany  being 
rare  in  regions  where  goitre  is  endemic.  In  the 
Tyrol,  where  goitre  is  endemic,  tetany  is  extremely 
rare.     In  a  later  article  Chvostek  states  that  he  re- 


MEDICAL    TETANY  321 

gards  mechanical  hypersusceptibility  of  nerves,  first 
the  facial,  as  an  easily  demonstrable  and  essential 
symptoms  of  disease  of  the  parathyroids,  a  fine  test 
which  shows  functional  disturbance  of  these  bodies. 
The  appearance  of  the  facial  phenomenon  in  cases 
of  pulmonary  tuberculosis  can  be  explained  by  the 
view  that  tuberculous  lesions  are  in  the  apex  and. 
thus  affect  the  parathyroids.  Chvostek's  view  is 
supported  by  the  case  of  Stumme  in  which  a  distinct 
facialis  phenomenon  was  benefited  by  the  removal 
of  a  tuberculous  parathyroid  during  thyroidectomy 
on  account  of  goitre. 

In  this  connection  a  case  that  can  be  included  in 
the  tetany  accompanying  infection  is  reported  by 
Carnot  and  Delion,  who  observed  during  the  terminal 
period  of  a  pulmonary  phthisis  various  convulsive 
movements,  with  loss  of  consciousness,  which  lasted 
several  days.  The  autopsy  showed  absence  of  men- 
ingitis, the  kidneys  were  practically  normal,  the 
thyroid  was  sclerosed,  but  especially  interesting  was 
the  condition  of  the  parathyroids.  The  inferior 
glandules  showed  sclerosis  and  infiltration,  the  right 
superior  was  not  found,  the  left  superior  showed  ex- 
tensive caseation. 

Frankl-Hochwart  has  called  attention  to  the  fact 
that  persons  who  have  had  tetany  usually  continue 
to  show  some  symptoms  during  the  rest  of  their 
lives. 

Gastric  Tetany. — In  gastric  tetany  MacCallum 
has  found  what  appears  to  be  evidence  of  hyper- 
function  of  the  parathyroids.  In  this  case  five  glan- 
dules were  found,  rather  large  in  size,  which  showed 
especially  large  groups  of  functioning  cells,  as  well 


322  PARATHYROID    GLANDS 

as  a  considerable  development  of  mitotic  figures  in 
the  principal  cells.  The  author  suggested  that  in 
this  case  the  enormously  dilated  stomach  elaborated 
more  material  than  the  parathyroids  were  normally 
called  upon  to  neutralize,  and  that  this  failure  of 
neutralization  of  the  toxin  gave  rise  to  the  severe 
tetany  from  which  the  patient  died. 

Koenigstein  also  reported  a  case  of  gastric  tetany 
in  which  similar  changes  in  the  parathyroids  were 
found,  as  well  as  characteristic  tinctorial  reactions 
to  iodine  and  Best's  glycogen  stain  that  could  not 
be  observed  in  normal  glands. 

In  opposition  to  this  concept  Erdheim  found  the 
parathyroid  glands  perfectly  normal  in  two  cases  of 
gastric  tetany.  The  first  patient  was  a  thirty-eight 
year  old  woman,  the  second  a  fifty-four  year  old 
woman.  Autopsy  showed  marked  stomach  dilata- 
tion in  both  cases  and  in  both  cases  the  functioning 
cells  of  the  parathyroids  (in  contradistinction  to  the 
previous  cases),  were  relatively  few. 

Kinnicutt  has  reported  a  case  of  gastric  tetany 
in  which  the  parathyroid  glandules  (examined  by 
Opie),  exhibited  no  abnormality.  In  this  case  the 
tetanic  symptoms  were  promptly  relieved  by  cal- 
cium salts,  but  parathyroid  nucleoproteid  given  by 
the  mouth  had  practically  no  effect  on  the  nervous 
system. 

Pfeiffer  and  Mayer  have  tried  to  produce  gastric 
tetany  in  the  dog  but  without  success. 

Children's  Tetany. — We  have  already  noted  cer- 
tain lesions  (hemorrhage)  of  the  parathyroid  glands 
that  have  been  found  in  children  exhibiting  tetany. 
It  appears  that  the  parathyroids  of  the  infant  are 


MEDICAL    TETANY  323 

disposed  toward  hemorrhage,  which  may  especially 
be  brought  about  by  intrauterine  asphyxia.  Erd- 
heim  has  observed  hemorrhage  in  three  cases  of  in- 
fant's tetany,  and  suggests  that  while  the  lesion 
does  not  necessarily  bring  on  this  condition  it  pre- 
disposes to  it.  In  one  of  this  author's  cases,  dying  in 
typical  tetany,  hemorrhage  was  found  in  all  four 
parathyroid  glands. 

Koenigstein  has  also  observed  changes  in  the  para- 
thyroid glands  in  two  cases  of  children's  tetany  con- 
sisting in  relative  increase  in  size,  hemorrhage  and 
tinctorial  differences  in  the  iodine  and  glycogen  re- 
actions. 

Thiemisch  found  the  parathyroids  normal  in  three 
cases  of  children's  tetany.  These  cases  have  been 
criticised,  however,  as  not  being  representative  cases 
of  this  condition. 

Verebely  describes  two  cases  of  hemorrhage  in  the 
parathyroids  of  children  in  which  there  was  no  tetany. 
Escherich  describes  a  case  of  tetany  in  a  seven  year 
old  boy,  occurring  in  the  course  of  a  tuberculous  men- 
ingitis, in  which  the  parathyroids  showed  marked 
degenerative  changes  which  might  well  have  led  to 
impairment  of  function.  This  author  believes  that 
the  parathyroid  theory  of  tetany  explains  in  a  very 
positive  manner  the  enormous  frequency  of  tetany 
in  the  earliest  period  of  life,  and  he  calls  attention 
to  the  fact  that  it  is  not  necessary  to  demonstrate 
anatomic  changes  in  the  parathyroids  in  all  instances, 
for  a  functional  deficiency  may  easily  occur  without 
histologic  changes  being  demonstrable. 

One  of  the  most  valuable  studies,  and  one  of  the 
most  convincing  as  regards  the  parathyroid  origin 


324 


PARATHYROID    GLANDS 


of  tetany,  is  that  contributed  by  Yanasse.  He  ex- 
amined the  parathyroids  in  eighty-nine  children 
showing  tetanoid  conditions,  particularly  galvanic 
changes  in  the  peripheral  nerves.  Hemorrhages  in 
parathyroids  were  found  in  thirty-three  cases,  (37 
per  cent).  Yanasse  asserts  that  the  hemorrhages  are 
acquired  mainly   in   postfetal   life,  perhaps  as  with 


Fig.  74.  A  parathyroid  glandule  of  the  sclerotic  type,  from  a  case 
of  infantile  atrophy.  The  dark  masses  represent  the  parenchyma; 
the  light  areas  the  increased  connective  tissue.  Above  (6)  is  thyroid 
gland.  Below  (c)  is  a  remnant  of  the  tissue  continuous  with  the  inter- 
scapular gland.    (Magnified  105.) 

pleural  and  pericardial  ecchymoses,  at  the  time  of 
birth.  Hemorrhages  in  these  glands  can  be  demon- 
strated with  certainty  only  during  the  first  year  of 
life;  after  this  the  possibility  progressively  becomes 


MEDICAL    TETANY  325 

smaller  and  after  the  fifth  year  one  cannot  say  from 
histologic  study  that  hemorrhage  had  ever  occurred. 
Late  hemorrhage,  in  older  children  or  adults,  seldom 
occurs.  Yanasse  divides  the  fifty  cases  in  which  the 
electrical  reaction  was  determined  into  four  groups : 
Normal  galvanic  reaction,  thirteen  cases.  In  twelve 
there  were  four  each,  in  one  three  parathyroids. 
Hemorrhage  was  found  in  none.  Group  2.  Anodal 
irregularity,  twenty-two  cases ;  hemorrhage  in  twelve 
or  54  per  cent.  In  the  ten  other  cases  the  age  must 
be  considered.  Of  the  twenty -two,  nine  were  in  the 
first  year  of  life  and  all  showed  hemorrhages.  Thir- 
teen were  above  one  year  and  hemorrhage  was  found 
sparely  in  three  and  was  absent  in  ten.  Therefore, 
all  ten  of  the  negative  cases  were  of  such  age  that 
signs  of  hemorrhage  could  have  disappeared.  Hem- 
orrhage was  found  in  eight,  or  61  per  cent.  The  other 
five  were  all  over  one  year.  Group  4.  Two  cases, 
one  of  tetany  with  meningitis  in  a  child  of  two  and 
a  half  years,  and  one  of  muscle  cramp  in  a  child  of 
three  months.  Hemorrhage  was  found  in  both. 
Eleven  (ten  under  one  year),  of  thirty -nine  cases  in 
which  the  electrical  reaction  was  not  taken  showed 
hemorrhage.  Certainly  it  was  not  accidental  that 
all  cases  with  normal  reactions  had  normal  parathy- 
roids and  that  all  cases  with  hemorrhage,  that  were 
tested  electrically,  showed  abnormal  reactions,  or 
clinically  forms  of  spasm.  Yanasse  concludes  that 
between  parathyroid  hemorrhage  and  tetany  there 
is  doubtless  a  connection.  The  question  is,  what  is 
this  connection?  His  explanation  is  as  follows: 
It  has  been  proved  experimentally  that  the  parathy- 
roids are  poison-destroying  organs  whose  principal 


326  PARATHYROID    GLANDS 

function  most  probably  is  to  neutralize  metabolic 
poisons  which  are  detrimental  to  the  nervous  sys- 
tem. Therefore  we  must  recognize  in  metabolism 
the  origin  of  the  so-called  tetany  poison,  in  the  nerves 
the  principal  tissue  attacked  by  it,  and  in  the  para- 
thyroids the  organ  that  neutralizes  this  poison.  The 
total  loss  of  parathyroids  causes  in  man  and  animals 
tetany  -of  which  the  clinical  picture  is  essentially 
like  that  of  other  forms  of  tetany.  Hemorrhage  in 
the  parathyroids  does  not  totally  destroy,  but  only 
partly  damages  the  glands,  hence  it  is  not  the  actual 
cause  or  alone  the  cause  of  tetany  but  it  can  so  act 
as  finally  to  produce  that  affection.  The  poison  in- 
creases because  the  parathyroids  damaged  by  hem- 
orrhage no  longer  exert  their  usual  function.  Only 
in  this  way  can  be  explained  how  parathyroid  hem- 
orrhage early  in  postfetal  life  leads  in  many  cases  to 
tetany  much  later  in  the  life  of  the  affected  in- 
dividual. 

Rickets  and  Osteomalacia. — It  is  quite  recently 
that  the  suggestion  has  been  made  that  there  may 
be  some  relationship  between  the  parathyroid  gland 
and  these  diseases.  In  the  course  of  both  diseases, 
as  is  well-known,  tetany  may  occur.  The  most  im- 
portant fact  that  has  been  developed  in  this  line  is 
the  observation  of  Erdheim,  who  noted  the  changes 
in  the  teeth  of  rats  which  we  have  previously  chron- 
icled. Moreover,  in  these  diseases  there  is  obviously 
some  profound  disturbance  of  calcium  metabolism, 
and  MacCallum  has  shown  the  intimate  relation  that 
exists  between  the  parathyroid  glands  and  calcium 
metabolism.  It  is  from  this  latter  observation  that 
we  may  hope  to  solve  this  question  rather  than  from 


MEDICAL    TETANY  327 

any  distinct  changes  that  have  been  observed  in 
the  glands,  although  such  have  been  noted.  Erd- 
heim  found  in  an  autopsy  on  a  case  of  osteomalacia 
a  noticeable  hypoplasia  of  the  parathyroids,  but  in 
a  second  case  these  glandules  were  entirely  normal. 
Hecker,  who  has  discussed  this  relationship,  thiriks 
that  there  is  probably  some  disturbance  of  the  para- 
thyroids in  both  osteomalacia  and  rickets  and  calls 
attention  to  the  fact  that  lack  of  calcium  in  the  or- 
ganism leads  to  tetany  and  that  calcium  metabolism 
is  doubtless  influenced  by  the  parathyroid  glands. 

Kassowitz  has  suggested  that  rickets  might  be  the 
underlying  basis  of  the  tetany  of  children  and  Esch- 
erich  has  suggested  congenital  parathyroid  hypo- 
plasia as  an  etiological  factor  in  rachitis. 

Weichselbaum  states  that  he  has  found  noticeable 
enlargement  of  the  parathyroid  glandules  in  rachitis. 

The  chronic  nutritional  disturbances  on  which  we 
have  laid  so  much  emphasis  that  have  been  proven 
in  animals  to  be  a  result  of  the  impairment  of  the 
function  of  the  parathyroid  glands  must  also  be 
borne  in  mind  in  considering  the  parathyroid  etiology 
for  these  diseases.  From  a  morphological  stand- 
point, however,  we  have  little  ground  for  such  as- 
sumption. Schmorl  who  has  examined  the  para- 
thyroids in  six  cases  of  rickets  found  no  changes. 
In  three  out  of  four  cases  of  osteomalacia  the  para- 
thyroids were  also  normal,  but  in  the  fourth  case  one 
hypoplastic  glandule  was  found. 

Eclampsia,  Tetany  of  Pregnancy  and  Lacta- 
tion.— The  role  of  the  parathyroids  in  the  tetany 
of  pregnancy  was  one  of  the  first  suggestions  point- 
ing towards  the  function  of  these  bodies.     Vassale 


328  PARATHYROID    GLANDS 

and  Generali,  in  1896,  noted  that  partially  parathy- 
roidectomized  animals,  which  usually  showed  only 
light  and  transitory  tetanic  symptoms,  were  apt  to 
develop  severe  tetany  during  pregnancy  and  the 
puerperium.  Vassale  removed  from  a  dog  three  of 
the  four  parathyroids.  Eighteen  months  after  the 
operation  the  dog  gave  birth  to  eight  puppies.  On 
the  fifth  day  of  lactation  it  was  taken  with  severe 
convulsions  which  seemed  to  be  relieved  by  taking 
away  several  of  the  puppies  and  feeding  with  thyroid 
extract.  The  convulsions  were  renewed,  however, 
and  combated  anew  with  the  thyroid  extract, 
which  was  continued  to  the  end  of  lactation  and  the 
dog  recovered. 

Verstraeten  and  Vanderlinden  had  previously 
noted  in  a  thyroidectomized  cat,  (partial  para- 
thyroidectomy), the  appearance  of  eclampsia  at  the 
time  of  parturition,  three  months  after  the  operation. 
The  symptoms  were  severe  but  were  ameliorated  by 
subcutaneous  injections  of  fresh  sheeps'  thyroid,  and, 
following  accouchement,  the  animal  recovered. 

Lanz  has  also  observed,  without  any  apparent 
thought  of  the  parathyroids,  that  pregnant  cats 
can  not  withstand  so  great  a  loss  of  thyroid  as  the 
non-pregnant  animals.  He  noted  that  after  a  con- 
siderable amount  of  the  thyroid  gland  had  been  re- 
sected (which  probably  included  several  of  the  para- 
thyroids), the  pregnant  cats  frequently  developed 
severe  tetany.  Halsted  found  that  a  pregnant  dog 
.from  which  the  thyroid  had  been  removed  (thyro- 
parathyroidectomy),  was  taken  near  the  end  of 
pregnancy  with  tetany  and  died. 


MEDICAL    TETANY  329 

Lange,  also  operating  on  cats,  who  removed  four- 
fifths  of  the  thyroid  (including  of  course  a  consider- 
able amount  of  parathyroid  tissue),  noted  that  out 
of  ten  pregnant  animals  five  died  in  coma,  three 
after  having  shown  convulsions.  The  author  de- 
scribed renal  and  hepatic  lesions  in  these  animals. 

Moussu  criticised  the  preceding  experiments  on 
the  ground  that  the  thyroidectomy  probably  pro- 
voked renal  lesions  which  were  responsible  for  the 
eclampsia.  He  performed  the  same  experiments  on 
four  goats  (thyroidectomy),  three  of  which  came  to 
accouchement  without  accident  save  for  a  transient 
albuminuria  in  one;  the  fourth  suffered  from  severe 
convulsions  during  the  third  month  of  the  preg- 
nancy (twenty-five  days  after  the  operation).  These 
experiments  of  Moussu  are  in  favor  rather  than 
against  the  parathyroid  theory  of  eclampsia  for  in 
the  goat  one  can  remove  very  frequently  the  entire 
thyroid  without  notable  interference  with  the  para- 
thyroid function.  His  experiments  are  more  to  be 
criticised,  as  well  as  those  of  Pineles,  Gross  and  Zan- 
frognini,  on  the  ground  that  they  were  undertaken 
on  already  pregnant  animals. 

Perhaps  the  most  important  contribution  to  this 
question  is  the  extensive  work  of  Thaler  and  Adler, 
who  operated  on  forty  female  rats,  which  they  ob- 
served carefully  for  two  hundred  days.  The  animals 
m  gestation  suffered  always  a  severe  tetany  following 
even  a  relatively  small  loss  of  parathyroid  tissue, 
while  the  non-gravid  animals  suffered  little  or  no 
tetany  from  a  similar  operation.  In  another  series 
of  experiments  non-gravid  rats  were  parathyroid- 
ectomized  and  watched  for  the  appearance  of  grav- 


330 


PARATHYROID    GLANDS 


idity.  Out  of  four  of  the  animals  from  which  one 
parathyroid  was  removed,  three  later  became  gravid 
and  two  of  them  died  from  tetany.  Of  twenty  ani- 
mals with  only  half  a  thyroid  fourteen  became  gravid 
and  died  without  exception  in  typical  tetany.  The 
tetany  usually  began  in  the  last  third  of  the  pregnancy 
and  the  non-fatal  cases  ended  with  parturition. 


Fig.  75.  Chronic  parathyroiditis.  The  epithelial  cells  are  crowded 
together  with  loss  of  original  structure  and  connective  tissue  greatly 
increased. 


This  significant  work  of  Thaler  and  Adler  was 
suggested  by  the  work  of  Erdheim  on  rats  which  we 
have  previously  quoted.  In  that  work  Erdheim  ob- 
served one  animal,  having  a  large  accessory  para- 
thyroid (both  parathyroids  had  been  removed), 
which  remained  free  from  tetany  until   it  became 


MEDICAL    TETANY  331 

pregnant,  when  it  suffered  typical  tetany  and  pre- 
mature delivery.  In  a  following  gravidity  the  tetany 
recurred  and  stopped  with  parturition. 

Frommer,  after  partial  removal  of  the  parathy- 
roids in  rabbits  has  injected  normal  human  placental 
tissue  into  the  abdominal  cavity,  with  the  result  that 
severe  disturbances  followed.  In  a  gravid  dog  three 
parathyroids  were  removed  and  some  tetanic  symp- 
toms occurred ;  five  days  after  the  operation,  twelve 
grams  of  human  placenta  was  introduced  into  the 
peritoneal  cavity;  four  days  later  during  parturition 
severe  tetanic  symptoms  appeared  but  the  animal 
later  recovered.  The  three  offsprings  died  although 
apparently  healthy  at  birth.  He  assumes  from  this 
that  the  parathyroids  have  an  antitoxic  function 
and  that  the  placental  tissue  was  toxic  in  this  ex- 
periment because  the  antitoxic  function  that  should 
have  been  supplied  by  these  glands  was  removed. 

In  a  later  article  Vassale  states  it  has  been  shown 
that  in  death  from  eclampsia  either  changes  in,  or 
congenital  absence  of,  one  or  two  parathyroids  is 
found.  Also  clinical  observations  show  that  para- 
thyroid therapy  gives  relief  against  the  convulsions 
in  eclampsia.  Moreover,  work  on  cats  and  mice 
shows  that  latent  parathyroid  insufficiency  in  the 
last  third  of  pregnancy  produces  experimental  eclamp- 
sia. In  two  out  of  three  dogs  in  which  the  para- 
thyroids were  removed  the  author  was  able  to  pre- 
vent the  eclampsia  of  pregnancy  by  means  of  admin- 
istration of  strong  doses  of  parathyroids  by  mouth. 
The  author  believes  the  effects  on  the  parathyroids 
in  childbirth  to  be  mechanical  and  not  autotoxic 


332  PARATHYROID    GLANDS 

and  that  the  longer  the  duration  of  the  birth  the 
more  danger  there  is  of  eclampsia. 

Gross  adds  to  a  rather  lengthy  discussion  of  the 
relation  of  functional  disturbances  of  the  parathyroid 
glands  to  tetany  the  following  two  experiments: 
In  two  pregnant  cats  he  removed  three  of  the  para- 
thyroids and  left  one  behind.  In  the  first  cat  mus- 
cular twitchings  in  the  facial  region  were  observed 
twenty-five  days  after  the  operation.  Twelve  days 
later  the  animal  gave  birth  to  healthy  young,  and 
the  twitching  ceased.  The  second  animal  showed 
no  symptoms. 

We  have  already  referred  to  rather  slight  anatomi- 
cal changes  found  in  the  parathyroids  in  cases  of 
eclampsia  by  Pepere,  Zanfrognini  and  Erdheim. 
These  are  too  minute,  however,  to  be  given  any 
marked  consideration. 

Mossaglia,  on  the  ground  of  experimental  work, 
believes  that  the  eclampsia  is  secondary  to  kidney 
changes.  He  states  that  parathyroid  deficiency  leads 
to  diminished  kidney  function  and  albuminuria,  and 
that  it  is  the  influence  of  the  parathyroid,  not  di- 
rectly, but  on  the  kidney  that  is  responsible  for  this 
condition.     Quadri  holds  a  similar  view. 

The  recent  work  of  MacCallum  offers  the  most 
plausible  theory  for  these  forms  of  tetany.  This 
author  states  that  in  the  tetany  that  accompanies 
pregnancy  and  lactation  the  drain  of  calcium  in  the 
production  of  the  fetus  or  on  the  secretion  of  milk 
may  be  so  great  as  to  cause  tetany  without  lesion  of 
the  parathyroid  glands.  If,  however,  the  function- 
ing power  of  these  organs  is  impaired  just  so  much  is 


MEDICAL    TETANY  333 

the  calcium  content  of  the  tissues  diminished  and 
tetany  thus  the  more  liable  to  express  itself. 

As  to  the  general  relationship  between  tetany  and 
the  parathyroid  glandules,  Rudinger  has  given  the 
opinion,  based  on  his  own  work  as  well  as  a  study  of 
the  literature  of  the  subject,  that  all  forms  of  tetany 
rest  upon  a  parathyroid  insufficiency.  To  substan- 
tiate this  theory  the  author  removed  the  outer  para- 
thyroids of  cats  after  injecting  them  with  such 
poisons  as  calomel,  morphine,  atropine,  tuberculin 
and  ether.  Although  the  injection  of  the  substances 
mentioned  gave  rise  to  no  "nervous"  symptoms,  such 
as  increased  electrical  excitability  or  other  indica- 
tions of  tetany,  the  injection  plus  the  partial  para- 
thyroidectomy, did  give  distinct  tetany  in  some  ani- 
mals and  increased  susceptibility  to  tetany  in  others. 


CHAPTER  XX. 


PARATHYROID  THERAPY. 


The  evolution  of  our  knowledge  of  the  parathy- 
roid glands  has  come  along  in  logical  sequence.  At 
first  we  were  concerned  with  the  anatomy  of  these 
bodies ;  then  came  the  experimental  work  in  animals 
revealing  the  results  of  their  loss.  This  work  was 
followed  by  a  consideration  of  the  application  of 
this  experimental  knowledge  to  symptoms,  post- 
operative and  other,  in  the  human,  and  finally  we 
arrive  at  the  stage  when  effort  centers  itself  in  an 
attempt  to  combat  or  modify  these  symptoms. 
Naturally  with  our  present  knowledge  of  organo- 
therapy at  hand  the  use  of  the  parathyroid  glands 
themselves  was  first  offered  for  such  combat. 

Diet. — It  was  found  after  the  first  parathyroidec- 
tomies were  performed  that  the  severe  metabolic 
disturbances  arising  from  parathyroid  excision  could 
be  modified  by  diet,  to  a  slight  extent  at  least.  Fast- 
ing animals,  it  was  found,  failed  to  develop  tetany 
as  soon  or  with  such  severity  as  well  fed  animals. 
Feeding  on  a  diet  of  bread,  or  of  bread  and  milk 
seemed  to  be  more  favorable  to  the  animal  than  a 
meat  diet.  Berkeley  and  Beebe  state  that  they  have 
observed  symptoms  in  an  operated  animal  from  one 
to  five  hours  after  a  heavy  meal  of  meat,  and  that 
they  have  occasionally  made  use  of  this  method  to 


PARATHYROID    THERAPY  335 

bring  on  tetany  at  a  favorable  time  for  experimental 
work.     These  authors  use  this  point  to  emphasize 
the  toxin  hypothesis  of  parathyroid  tetany,  bring- 
ing in  as  collateral  evidence  the  fact  that  a  meat  diet 
predisposes  to  convulsions  in  those  cases  of  preg- 
nancy which  have  disturbances  of  metabolism  char- 
acteristic of  the  preeclamptic  state.     These  authors 
state:     "The  nitrogen  partitions  in  the  urine  in  such 
patients  are  in  most  cases  abnormal,  with  relatively 
high  ammonia,  high  rest  nitrogen,  notable  quanti- 
ties  of  kreatinin,    but   with   diminished   urea   and 
kreatinin  excretion.     Such  findings  indicate  severe 
nutritional  disturbance,  and  the  possibility  of  meta- 
bolic toxins  being  responsible  for  the  symptoms  in 
such  cases  is  commonly  accepted.     The  means  of 
relief  in  acute  conditions  by  the  very  active  stimu- 
lation of  excretion  through  skin,  bowel,  and  kidney, 
through  the  use  of  the  hot  pack,  diaphoretics,  purga- 
tion, the  high  saline  irrigation,  vigorous  diuresis,  and 
occasionally  by  bleeding  and  saline  infusion  are  all 
based  on  the  belief  that  the  symptoms  are  caused 
by  an  active  toxic  substance  in  the  circulating  blood. 
A  similar  method  of  treatment  is  of  clinical  value  in 
the  treatment  of  parathyroid  tetany.     The  fact  that 
under   disturbed   conditions    of   nitrogenous   meta- 
bolism a  meat  diet  gives  rise  to  metabolic  products 
which  may  provoke  convulsions  suggests  that  the 
meat  diet  has  more  than  a  passive  role  in  producing 
the  symptoms  of  parathyroid  tetany." 

Parhon  and  Goldstein  have  found  that  maternal 
milk  feeding  prolongs  life  after  thyroparathyroidec- 
tomy.  Suckling  kittens  did  not  die  so  soon  after  this 
operation  as  kittens  fed  on  a  partial  meat  diet. 


336  PARATHYROID    GLANDS 

MacCallum  supports  the  calcium  deficiency  hypo- 
thesis by  the  suggestion  that  the  high  content  of 
calcium  in  milk  is  the  factor  that  makes  it  a  more 
favorable  diet  than  meat  for  parathyroidectomized 
animals. 

We  have  already  referred  to  the  fact  that  in  the 
early  study  of  the  function  of  the  thyroid  the  error 
was  made  that  carnivora  could  not  withstand  the 
loss  of  that  gland  while  herbivora  bore  its  loss  fre- 
quently without  acute  symptoms.  This  observa- 
tion, however,  had  nothing  to  do  with  diet  but  rested 
on  a  lack  of  knowledge  of  the  anatomy  of  the  para- 
thyroids. In  the  dog  (carnivora)  removal  of  the 
thyroid  included  removal  of  all  the  parathyroids, 
while  in  the  rabbit  (herbivora)  such  removal  did  not 
include  the  two  external  parathyroids  which  are 
quite  separate  from  the  thyroid  and  therefore  pro- 
tected the  animal  from  tetany. 

Transfusion  has  also  been  tried  in  animals  exhi- 
biting tetany,  on  the  ground  that  some  poisonous 
material  was  circulating  in  the  blood  of  the  operated 
animal.  MacCallum  and  Davidson  introduced  the 
blood  of  a  normal  dog  into  a  dog  with  tetany  with 
the  result  that  the  symptoms  rapidly  and  completely 
disappeared.  The  tetany  recurred  the  next  day  and 
the  dog  was  bled  and  a  considerable  quantity  of 
salt  solution  allowed  to  run  into  its  veins.  This 
again  stopped  the  tetany,  but  again  it  returned  on 
the  following  day.  The  infusion  was  repeated  with 
success,  but  the  dog  passed  gradually  into  a  state  of 
cachexia  and  died  after  several  days. 

Colzi,  Fano  and  Zanda  and  Cannezzaro  have  also 
noted  the  favorable  influence  of  bleeding  and  trans- 


PARATHYROID    THERAPY  337 

fusion  of  blood  from  a  normal  animal  on  the  symp- 
toms of  tetany  produced  by  thyroidectomy  (thyro- 
parathyroidectomy) .  Fano  and  Zanda  have  also 
observed  the  same  effects  from  infusion  of  salt  solu- 
tion. These  experiments  were  made  before  the  re- 
lationship of  tetany  to  the  parathyroid  glandules  had 
been  suggested. 

Pfeiffer  and  Mayer  injected  a  parathyroidectom- 
ized  dog  with  ox  serum,  beginning  the  day  after  the 
operation,  during  the  latent  period  and  again  on  the 
second,  fifth  and  eighth  day.  Following  the  second 
and  third  injection,  done  while  the  animal  was  appar- 
ently at  the  point  of  death,  was  combined  bleeding 
and  the  subcutaneous  injection  of  warm  salt  solu- 
tion. This  gave  almost  immediate  relief  which  was, 
however,  only  temporary  and  the  dog  died. 

Parathyroid  Therapy . — The  therapeutic  use  of  the 
glands  themselves  has  been  practiced  extensively  from 
the  time  the  symptoms  resulting  from  parathyroid- 
ectomy were  first  established.  Vassale  obtained 
results  from  the  use  of  thyroids  in.  which  parathy- 
roids were  included  in  1890,  and  his  work  was  con- 
firmed by  Gley  in  1891. 

One  of  the  most  striking  results,  and  one  that  later 
investigators  have  not  been  able  to  repeat,  was  that 
obtained  by  Lusena.  This  author  kept  a  dog  alive 
for  four  months  after  removal  of  the  parathyroids 
by  subcutaneous  injections  of  parathyroid  emulsions 
for  eight  days  followed  by  transplantation  of  one 
parathyroid  subcutaneously  every  fifteen  days.  It 
is  to  be  questioned  in  this  case  whether  the  parathy- 
roids were  completely  removed. 


338  PARATHYROID    GLANDS 

Edmunds  reports  feeding  a  large  quantity  of  para- 
thyroids to  an  animal  in  tetany  practically  without 
result,  and  Vincent  and  Jolly  state  that  they  were 
unable  to  prevent  the  onset  of  symptoms  in  the 
complete  operation  by  the  use  of  thyroid  or  para- 
thyroid tissues.  In  general,  however,  the  results  of 
parathyroid  feeding  and  injection  show  that  the 
symptoms  of  tetany  may  be  temporarily  stopped  by 
this  measure,  and  even  repeatedly,  but  that  eventu- 
ally the  animal  succumbs. 

MacCallum  and  Davidson  report  the  following  re- 
sults on  four  dogs.  In  the  first,  three  parathyroids 
from  the  cow  were  introduced  intraperit  one  ally  after 
tetany  had  begun ;  symptoms  continued  followed  by 
emaciation,  apathy  and  death  in  five  days.  In  the 
second,  beef  parathyroid  and  morphine  were  in- 
jected subcutaneously;  next  day  there  was  no  tetany 
but  the  following  day  tetany  recurred  and  the  animal 
died.  In  the  third,  one  intravenous  injection  of 
parathyroid  emulsion  stopped  the  symptoms  of  tet- 
any but  five  days  later  the  dog  died  from  an  infec- 
tion. The  history  of  the  fourth  animal  is  interesting. 
After  the  development  of  tetany  the  parathyroids 
of  twenty  dogs  were  injected  into  the  jugular  vein. 
This  stopped  the  tetany  but  it  recurred  and  the  para- 
thyroids of  thirty-seven  dogs  were  injected.  The 
symptoms  did  not  return  for  three  days  and  then 
the  parathyroids  of  twenty-two  dogs  were  injected 
into  the  peritoneum.  Again  symptoms  ceased  only 
to  recur  four  days  later  when  the  parathyroids  of 
eighteen  dogs  were  injected  with  the  usual  cessation 
of  symptoms.  Three  days  later  the  symptoms  again 
recurred  and  no  further  supply  of  parathyroids  be- 


PLATE  XXXIX 


p.t..__ 


P.  T.       INFERIOR   PARATHYROIDS    ON    ANTERIOR    INFERIOR    SURFACE   OF   THE 
THYROID    (A  RARE   SITUATION). 


PARATHYROID    THERAPY  339 

ing  available  the  animal  died  of  tetany.  This  ex- 
periment seems  to  show  very  conclusively  that  the 
life  of  a  dog  can  be  maintained  temporarily  after 
complete  parathyroidectomy  by  the  use  of  a  great 
amount  of  material,  but  that  when  therapy  stops  the 
symptoms  recur  and  the  animal  dies.  Cases  that 
are  reported  as  recovering  permanently  from  symp- 
toms of  tetany  after  the  injection  of  one  or  two  para- 
thyroid glands  are  undoubtedly  cases  in  which  the 
parathyroids  were  not  entirely  removed. 

Moussu  was  able  to  arrest  postoperative  tetany  in 
dogs  by  the  subcutaneous  and  intravenous  injection 
of  extracts  of  the  horse  parathyroid.  His  results 
were  only  temporary  as  nearly  all  the  dogs  died 
later  in  a  cachectic  condition.  Alquier  and  Theun- 
veny  report  similar  results  in  dogs. 

Esterbrook  was  probably  the  first  to  administer 
parathyroid  glandules  to  the  human  subject.  He 
employed  ox  parathyroids  in  insane  patients  with 
no  particular  reference  to  symptoms  of  tetany,  but 
merely  to  compare  the  results  of  parathyroid  feeding 
with  those  obtained  from  the  use  of  the  thyroid 
gland.  Esterbrook  first  gave  one  dried  ox  parathy- 
roid by  the  mouth  every  day  for  a  week ;  two  glands 
a  day  were  given  the  next  two  days,  and  three  on  the 
next  three  days.  Then  hypodermatic  injections  were 
administered.  These  were  followed  by  glycerine 
extracts  of  the  glands.  In  one  case  as  many  as  nine 
parathyroids  were  given  daily.  From  this  treat- 
ment practically  no  effects  were  obtained;  tempera- 
ture, pulse  and  respiration  remained  normal,  urinary 
nitrogen  and  phosphoric  acid  showed  no  change. 
Only  a  slight  increase  in  pulse  tension  was  observed. 


340  PARATHYROID    GLANDS 

These  results  were  so  different  from  the  striking 
symptoms  following  the  use  of  thyroid  extract  that 
the  author  assumed  that  the  symptoms  arising  from 
parathyroidectomy  were  due  to  injury  to  the  thyroid 
or  its  nerve  connections  rather  than  to  removal  of 
the  parathyroids. 

In  1901  Moussu  and  D'Ausset  at  the  Congress  of 
Gynecology  in  Nantes,  reported  cases  of  tetany  bene- 
fited by  thyroid  therapy  (the  internal  parathyroids 
being  included  in  the  thyroid  extract.) 

Scanning  the  literature  since  this  time  we  find 
many  favorable  reports  on  the  use  of  these  glands 
in  a  wide  range  of  diseases  showing  symptoms  of 
tetany.  And  while  in  many  instances  it  does  appear 
that  their  employment  has  been  of  real  value,  never- 
theless the  suggestive  effect  of  such  treatment  must 
be  borne  in  mind. 

Vassale  by  the  use  of  a  parathyroid  extract  pre- 
pared in  a  special  manner,  the  details  of  which  he 
fails  to  disclose,  reports  beneficial  results  when  used 
either  by  mouth  or  subcutaneously  on  cases  of 
eclampsia,  infantile  tetany  and  epilepsy,  and  thinks 
it  would  be  equally  efficacious  in  all  varieties  of  tetany. 

Berkeley  has  employed  parathyroid  therapy  on 
eleven  cases  of  paralysis  agitans  in  various '  stages 
of  the  disease.  He  reports  that  nine  of  these  patients 
showed  improvement,  the  earlier  cases  especially, 
and  one  very  early  case  considered  himself  nearly 
relieved  while  under  the  influence  of  the  treatment. 
'  'All  the  patients  remarked  upon  a  curious  increase  in 
courage,  comfort  and  mental  energy,  while  taking 
the  remedy."  Castelvi  has  reported  equally  good 
results  in  this  disease  by  the  use  of  thyroid  extracts. 


PARATHYROID    THERAPY  341 

Zanfrognini  has  employed  parathyroid  therapy  in 
five  cases  of  eclampsia  with  general  improvement  of 
symptoms.  Michelazzi  also  reports  favorable  results 
in  eclampsia  from  the  use  of  parathyroids. 

Rensburg  arid  Rey  obtained  completely  negative 
results  with  parathyroid  therapy  in  infant's  tetany; 
and  Spieler  likewise  had  no  result  following  the  use 
of  parathyroid  tablets  in  this  disease. 

Loewenthal  and  Wiebrecht  have  reported  good 
results  in  many  instances  following  parathyroid  feed- 
ing in  tetany.  Marinesco  has  reported  favorable 
results  following  the  use  of  ox  parathyroid  in  a  seven- 
teen-year-old girl,  suffering  from  exophthalmic  goitre 
combined  with  intermittent  tetany. 

Murraron  reports  having  suspended  epileptiform 
attacks  in  two  goitrous  cretins  by  the  use  of  para- 
thyroid extract,  and  Mant  and  Shaw  apparently 
cured  by  the  same  means  a  young  girl  of  nine  years 
suffering  from  tetany  in  connection  with  grave  gas- 
trointestinal symptoms. 

Brandan  reports  a  case  where,  after  the  removal 
of  a  colloid  goitre  from  a  girl  aged  fourteen  years, 
tetany  developed  forty-eight  hours  after  the  opera- 
tion. By  the  use  of  subcutaneous  injections  of  para- 
thyroid emulsion  the  symptoms  disappeared,  and 
the  patient  has  remained  free  from  the  same  for  one 
year.  This  phenomenon  is  explained  by  the  fact  that 
the  parathyroids  were  probably  not  all  removed  at 
operation,  but  were  so  damaged  that  their  function 
was  suspended  temporarily,  and  that  the  parathyroid 
emulsion  sustained  the  patient  until  the  glandules 
resumed  their  normal  work,  possibly  by  compensa- 
tory hypertrophy. 


342  PARATHYROID    GLANDS 

Berkeley  has  relieved  symptoms  of  gastric  tetany 
in  a  thirty-nine  year  old  man  by  oral  administration 
of  fresh  ox  parathyroid.  Putnam  has  reported  ef- 
fective relief  in  a  case  of  surgical  tetany  by  the  use 
of  a  similar  preparation. 

Beebe  was  the  first  to  prepare  and  administer  a 
nucleoproteid  principle  of  the  parathyroid  gland, 
which  has  been  quite  active  in  dispelling  the  symp- 
toms of  tetany.  In  a  later  paper  Berkeley  and  Beebe 
give  in  detail  the  methods  for  preparing  this  ex- 
tract from  beef  parathyroids  obtained  by  roughly 
trimming  out  the  small  mass  of  tissue  containing 
the  two  superior  glands.  "The  carefully  cleaned 
glands  were  cut  into  small  pieces  with  scissors,  and 
the  comminuted  tissue  was  then  ground  to  a  fine 
pulp  in  a  large  mortar  with  the  help  of  enough  sand 
to  give  the  whole  mass  a  moist,  pasty  consistency. 
The  crushed  glands  were  next  shaken  for  two  hours 
at  room  temperature  with  six  to  eight  volumes  of 
physiological  salt  solution  to  which  had  been  added 
two  drops  of  ten  per  cent  sodium  hydroxide  solution. 
The  jar  was  now  transferred  to  the  refrigerator  and 
the  extraction  allowed  to  continue  for  eighteen  to 
thirty-six  hours.  Filtration  first  through  gauze,  to 
remove  the  fat  and  coarser  particles  of  tissue,  and 
then  through  moderately  thick  paper  gave  a  clear 
extract  which  was  preserved  by  the  addition  of  chloro- 
form and  kept  at  low  temperature  until  biologically 
tested." 

It  was  shown  that  an  extract  so  prepared  relieved 
the  symptoms  of  tetany  in  a  parathyroidectomized 
dog  in  ten  to  fifteen  minutes  after  injection.  As 
this  extract  contained  nucleoproteids,  globulins,  and 


PARATHYROID    THERAPY  343 

albumins  it  was  decided  to  separate  it  still  further, 
and  it  was  divided  into  three  portions.  The  first 
portion  was  precipitated  by  acetic  acid,  the  second 
by  half  saturating  the  filtrate  with  ammonium  sul- 
phate, and  the  third  by  complete  saturation  with 
ammonium  sulphate.  The  precipitate  from  the  first 
portion  (nucleoproteid)  was  most  abundant ;  the  sec- 
ond (globulin)  was  about  one -fifth  the  first ;  while  the 
third  (albumin)  was  so  small  that  it  was  abandoned. 
The  activity  of  these  proteids  is  summarized  by 
Beebe  as  follows: 

"1.  The  nucleoproteid  of  the  parathyroid  when 
freshly  prepared  is  equal  to  the  whole  gland  in  re- 
lieving the  symptoms  of  acute  tetany  in  dogs. 

2.  The  globulin  is  of  no  value  in  relieving  tetany. 

3.  Boiling  the  nucleoproteid  solution  or  heating 
it  to  80  degrees  C.  for  one-half  hour  completely  de- 
stroys the  activity  of  the  nucleoproteid. 

4.  The  nucleoproteid  is  most  active  when  freshly 
prepared  and  rapidly  deteriorates  when  kept  in  solu- 
tion or  in  suspension  at  refrigerator  temperature. 
Freezing  also  destroys  its  activity,  although  not  so 
rapidly  as  room  temperatures. 

5.  Tryptic  digestion  or  the  action  of  pepsin  and 
hydrochloric  acid  for  forty-eight  hours  severely  in- 
jures, but  does  not  completely  destroy,  the  activity 
of  the  nucleoproteid. 

6.  The  nucleoproteid  will  relieve  tetany  if  given 
by  mouth,  but  is  much  more  quickly  and  certainly 
effective  when  given  subcutaneously  or  intraperi- 
toneally . ' ' 

The  results  following  the  use  of  this  parathyroid 
nucleoproteid  are  strikingly  illustrated  by  its  efficacy 


344  PARATHYROID   GLANDS 

in  relieving  tetany  in  thirty-two  animals  as  detailed 
by  Berkeley  and  Beebe,  who  report  positive  results 


Fig.  76.  Transplantation  of  thyroid  and  parathyroid  into  the 
tibia  of  a  dog.  Some  thyroid  persists  (at  the  edge  of  the  section),  but 
the  parathyroid  has  undergone  necrosis.  The  animal  died  of  cachexia, 
with  no  tetany,  although  all  other  parathyroid  tissue  had  been  re- 
moved. 

in  ninety-five  per  cent  of  the  trials  in  which  a  com- 
paratively fresh  preparation  was  used.  The  boiled 
proteid,  and  the  globulin,  however,  always  gave  a 


PARATHYROID    THERAPY  345 

negative  result.     The  digested  proteids  gave  relief 
only  when  used  in  large  doses. 

The  clinical  value  of  the  nucleoproteid  has  also 
been  proved  in  cases  of  post  operative  tetany  in  the 
human  subject.  Halsted  reports  that  in  a  patient 
suffering  greatly  from  subtetanic  hypoparathyroid- 
ism as  the  result  of  two  operations  upon  a  large  colloid 
goitre,  tetany  has  for  two  years  been  averted -and 
the  condition  made  endurable  by  the  use  of  hypo- 
dermic injections  of  the  nucleoproteid  of  the  para- 
thyroid gland  (Beebe)  and  by  parathyroid  feeding. 

Pool  reports  a  case  of  a  young  woman  who  had 
had  two  thyroid  operations.  Despite  the  use  of 
Vassale's  serum  and  implantation  of  the  parathyroid 
glands  a  typical  tetany,  which  developed  four  days 
after  the  second  operation,  continued  for  thirteen 
months.  Improvement  was  finally  secured  by  re- 
peated administration  hypodermatically  of  large  doses 
of  Beebe 's  nucleoproteid. 

Calcium  Salts. — While  the  development  of  our 
knowledge  of  the  parathyroid  glands  has  been  fraught 
with  dramatic  incidents  throughout,  a  fitting  climax 
was  lacking  until  the  discovery  that  the  severe  tet- 
anic symptoms  arising  from  their  removal  could  be 
instantly  stopped  by  the  administration  of  soluble 
calcium  salts.  And  thus  a  new  field  of  investiga- 
tion was  opened  which  promises  to  lead  to  practical 
therapeutical  results  and  to  the  throwing  of  new 
light  on  certain  interesting  features  of  metabolism 
in  the  human  body. 

In  the  summer  of  1907,  Parhon  and  Urechie  in 
the  Revista  Stiintelor  Medicale  published  an  article 
on  the  influence  of  the  injection  of  sodium  chloride 


346  PARATHYROID    GLANDS 

and  calcium  chloride  into  animals  that  have  experi- 
mental tetany.  While  they  found  that  sodium  salts 
increased  the  tetany  of  parathyroidectomized  dogs, 
they  made  the  important  observation  that  one  gram 
of  calcium  chloride  dissolved  in  one-hundred  cc. 
of  water  and  injected  into  the  peritoneum  held  in 
check  all  acute  symptoms. 

Independently,  in  March,  1908,  MacCallum  and 
Voegtlin  published  a  communication  on  the  relation 
of  the  parathyroid  glands  to  calcium  metabolism  and 
the  nature  of  tetany,  which  they  have  followed 
(1909),  by  a  more  lengthy  and  detailed  account  of 
their  investigations  in  this  line. 

These  observations  rest  on  the  clinical  studies  of 
such  conditions  as  rickets  and  osteomalacia  which 
have  suggested  that  tetany  might  stand  in  relation 
to  disturbances  in  calcium  metabolism ;  and  further 
on  the  observations  of  J.  Loeb  and  J.  R.  MacCallum 
that  the  effects  of  various  salts  which  cause  muscu- 
lar twitching  may  be  counteracted  by  calcium.  More  - 
over,  the  observation  of  Erdheim  on  the  changes  in 
the  teeth  of  parathyroidectomized  rats  seems  to  have 
a  bearing  on  this  question. 

The  use  of  calcium  salts  in  tetany  had  previously 
been  recommended,  but  without  regard  to  the  para- 
thyroid glands.  Quest,  as  well  as  Silvestri  and  others, 
has  called  attention  to  the  low  calcium  content 
in  the  convulsive  stage  of  tetany,  and  Sabbatini 
noted  that  trisodic  citrate  solutions  would  cause  con- 
vulsions and  muscular  twitching  because  they  com- 
bine with  the  soluble  calcium  salts  in  the  body  fluids. 

Whether  we  accept  this  calcium  deficiency  hypo- 
thesis, or  consider  it  only  as  a  secondary  factor  in 


PARATHYROID    THERAPY  347 

the  cause  of  parathyroid  tetany  we  must  admit  that 
such  a  deficiency  exists  and  that  the  restoration  of 
calcium  to  the  tissue  will  prevent  the  tetany  due  to 
parathyroid  deficiency. 

The  same  effects  can  be  obtained  up  to  a  certain 
extent  by  the  use  of  soluble  salts  belonging  to  the 
same  natural  group  as  calcium,  such  as  magnesium, 
barium,  and  strontium. 

MacCallum  and  Voegtlin  were  able  to  relieve  the 
tetany  of  parathyroidectomized  animals  by  injections 
of  magnesium  salts,  but  found  it  was  too  dangerous 
a  salt  to  use  on  account  of  its  depressant  action. 
Berkeley  and  Beebe  have  found  that  the  symptoms 
of  tetany  are  relieved  with  nearly  the  same  degree 
of  promptness  and  completeness  by  strontium  salts 
as  by  calcium  salts.  They  use  ten  c.  c.  of  a  ten  per 
cent  solution  of  strontium  chloride  to  a  ten  kilogram 
dog.  On  ten  animals  they  found  the  effect  of  stron- 
tium salts  differed  practically  not  at  all  from  the 
effects  obtained  by  the  use  of  calcium  salts.  These 
authors  also  found  that  barium  salts  will  relieve 
tetany,  but  that  they  should  never  be  given  as  a 
therapeutic  measure  because  an  efficient  therapeutic 
dose  is  too  near  the  border  line  of  a  fatal  dose. 

Berkeley  and  Beebe,  following  the  suggestion  of 
MacCallum  and  Voegtlin's  first  article,  have  tried  the 
effects  of  calcium  salts  on  a  number  of  dogs,  and 
while  they  agree  with  those  authors  that  calcium 
quickly  stops  the  symptoms  of  tetany,  they  consider 
that  the  symptoms  are  due  to  a  metabolic  poison, 
the  abnormal  excretion  of  calcium  being  an  accom- 
panying phenomenon:  They  cite  in  favor  of  this 
hypothesis  the  fact  that  the  symptoms  have  a  cen- 


348  PARATHYROID   GLANDS 

tral  origin;  that  symptoms  are  shown  best  in  young 
animals,  and  are  more  severe  if  the  animal  has  been 
kept  on  a  meat  diet ;  that  the  symptoms  have  a  close 
relation  to  certain  clinical  conditions  which  are  ac- 
companied by  severe  nutritional  disturbances.  More- 
over, that  gastric  tetany  is  accompanied  by  severe 
metabolic  disturbance,  it  has  similar  symptoms  and 
is  promptly  relieved  by  intravenous  calcium  injec- 
tions and  by  parathyroid  nucleoproteid;  that  bleed- 
ing, followed  by  intravenous  infusion,  relieves  tetany 
as  well  as  does  the  injection  of  fresh  parathyroid 
nucleoproteid.  In  addition  injection  of  poisons  such 
as  ammonia  and  xanthin  produce  symptoms  which 
can  be  promptly  relieved  by  injection  of  calcium  or 
strontium  salts,  and  it  is  known  that  increased  ex- 
cretion of  ammonia  follows  complete  thyroidectomy. 

The  work  of  MacCallum  and  Voegtlin,  which  marks 
so  important  an  epoch  in  our  knowledge  of  the  para- 
thyroid glands,  is  exhaustive  and  includes  a  consider- 
able study  of  metabolism  in  parathyroidectomized 
animals,  as  well  as  the  negative  effects  of  injection 
of  sodium  and  potassium  salts.  An  idea  of  the 
effects  obtained  by  these  authors  by  the  use  of  cal- 
cium salts  in  dogs  can  best  be  obtained  by  quoting  in 
detail  several  of  their  experiments. 

"Thyropara thyroidectomy ;  four  days  later  violent 
twitching  of  muscles,  pulse  160,  respiration  labored. 
Given  ten  c.  c.  of  a  five  per  cent  solution  of  calcium 
acetate  into  jugular  vein.  Respiration  became  rapid 
two  hundred  to  minute,  twitching  rare  but  sharp. 
Twenty-five  minutes  after  the  injection,  pulse  was 
eighty,  very  irregular  and  slow.  Dog  thought  to  be 
dying,    occasional   slight   twitches.     Next   day   dog 


PARATHYROID    THERAPY  349 

was  found  walking  about  and  fairly  well  but  was 
found  dead  the  day  after.  In  this  experiment  the 
animal  was  apparently  restored  to  life  from  a  mori- 
bund state,  but  the  amount  of  calcium  salt  had  not 
been  large  enough  to  remove  tetany  instantly." 

"January  9,  two  parathyroids  and  one  lobe  of 
thyroid  extirpated,  no  results.  January  18,  second 
lobe  of  thyroid  removed.  January  19,  violent  tet- 
any;  at  11 :30  given  ten  c.  c.  of  five  per  cent  calcium 
lactate    subcutaneously.  11:35,    respiration    240 

marked  twitching,  pulse  180,  breathing  very  rapid 
and  labored.  12:10,  still  tachypncea  and  twitching. 
1 :10,  respiration  slowed,  40  to  minute,  muscular 
twitching  still  marked.  1 :30,  respiration  quiet ; 
1:32,  twitching  has  almost  disappeared,  slight  mus- 
cular tremor,  walks  about  but  looks  dejected.  3 :00 
p.  m.,  respiration  24,  pulse  124,  dog  is  quite  normal 
in  appearance,  no  tremor  nor  twitching.  Respiration 
perfectly  quiet  and  animal  has  perfect  control  of 
himself  and  eats  hungrily  on  being  taken  to  cage." 

The  effects  of  the  administration  of  these  salts  are 
of  course  not  permanent.  The  dog  last  cited,  for 
instance,  developed  tetany  again  the  next  day.  This 
temporary  relief  may  be  of  permanent  value,  as  for 
instance  in  a  case  of  one  of  Halsted's  dogs  in  which 
tetany  was  tided  over  by  the  administration  of  cal- 
cium until  a  transplanted  parathyroid  became  able 
to  function  actively  enough  to  prevent  tetany. 

MacCallum  and  Voegtlin  also  cite  cases  in  which 
an  opportunity  to  observe  the  effect  of  calcium  upon 
cases  of  tetany  in  human  beings  has  been  offered. 
In  a  case  of  Musser's  in  which  violent  tetany  had  de- 
veloped, following  the  removal  of  a  malignant  growth 


350  PARATHYROID    GLANDS 

of  the  thyroid,  calcium  lactate  was  administered  in 
large  and  frequent  doses.  This  caused  the  disap- 
pearance of  the  tetany  in  the  course  of  one  day,  but 
with  the  cessation  of  calcium  medication  for  two  or 
three  days  the  symptoms  of  tetany  reappeared. 
Again  they  disappeared  with  the  renewal  of  the  cal- 
cium treatment.  A  second  case  occurring  in  the 
practice  of  a  New  York  physician,  responded  to  the 
administration  of  calcium  salts  in  the  same  way. 
And  a  third  case,  of  a  little  girl  suffering  from  gastric 
tetany  was  completely  relieved  by  the  administra- 
tion of  calcium. 

In  the  case  previously  cited  of  Halsted's,  in  which 
tetany  had  been  averted  for  two  years  by  the  use  of 
parathyroid  gland  extracts,  the  latter  reports  the 
same  effect  for  the  third  year  by  the  use  of  calcium 
salts. 

MacCallum  and  Voegtlin  summarize  the  role  of 
the  calcium  salts  in  connection  with  tetany  as  fol- 
lows :  '  'These  salts  have  a  moderating  influence  up- 
on the  nerve  cells.  The  parathyroid  secretion  in 
some  way  controls  the  calcium  exchange  in  the  body. 
It  may  possibly  be  that  in  the  absence  of  the  para- 
thyroid secretion,  substances  arise  which  can  com- 
bine with  calcium,  abstract  it  from  the  tissues  and 
cause  its  excretion  and  that  the  parathyroid  secre- 
tion prevents  the  appearance  of  such  bodies.  The 
mechanism  of  the  parathyroid  action  is  not  deter- 
mined, but  the  result,  the  impoverishment  of  the 
tissues  with  respect  to  calcium  and  the  consequent 
development  of  hyperexcitability  of  the  nerve  cells, 
and  tetany  is  proven.  Only  the  restoration  of  cal- 
cium to  the  tissues  can  prevent  this.     This  explana- 


PARATHYROID    THERAPY  351 

tion  is  readily  applicable  to  spontaneous  forms  of 
tetany  in  which  there  is  a  drain  of  calcium  for  physio- 
logical purposes,  or  in  which  some  other  condition 
causes  a  drain  of  calcium.  In  such  cases  the  para- 
thyroid glands  may  be  relatively  insufficient." 

Leopold  and  Reuss  found  a  slight  increase  rather 
than  a  decrease  of  calcium  in  adult  rats  exhibiting 
cachexia  parathyropriva,  including  enamel  defects 
of  the  teeth,  after  parathyroidectomy.  In  young  rats 
after  the  same  operation,  a  lowering  of  calcium  was 
observed  as  well  as  lack  of  growth  and  lack  of  weight 
increase. 

Parhon,  Dumitresco  and  Nissipesco  found  in  cats 
and  dogs  after  thyroparathyroidectomy,  an  increase 
of  calcium  in  the  nerve  centers. 

In  the  tetany  of  infants  Oddo  and  Sarles  have 
found  an  increased  amount  of  calcium  in  the  urine. 
In  a  case  of  post-operative  tetany  Musser  and  Good- 
man found  a  diminution  of  calcium  in  the  urine. 

TRANSPLANTATION  OF  THE  PARATHYROID  GLANDS. 

The  limitations  to  tissue  transplantation  in  warm 
blooded  animals  are,  of  course,  well  known.  When 
portions  of  various  glands  have  been  implanted  into 
regions  well  supplied  with  blood  they  soon  lose  their 
original  structure,  become  absorbed,  and  only  a  bit 
of  cicatrical  tissue  eventually  marks  the  site  of  trans- 
plantation. Certain  glands  have  responded  to  trans- 
plantation much  better  than  others,  especially  the 
thyroid.  It  has  been  found  in  the  cat  and  the  dog 
that  while  the  central  parts  of  transplanted  thyroid 
lobes  undergo  necrosis,  the  other  portions  may  per- 
sist, and  blood  vessels  from  surrounding  granulation 


352  PARATHYROID    GLANDS 

tissue  enter  and  give  life  to  an  apparent  new  growth 
of  the  gland,  including  even  lumina  filled  with  col- 
loid. 

It  is  of  extreme  interest  then  to  know  if  such  im- 
portant organs  as  the  parathyroid  glands  may  be 
transplanted  with  any  possibility  of  permanent  suc- 
cess in  saving  a  patient  from  tetany  or  death  follow- 
ing the  unfortunate  removal  of  these  bodies  as  has 
occurred  in  operations  involving  the  thyroid  gland. 

The  first  experiments  in  which  parathyroids  were 
successfully  transplanted  have  to  be  gathered  from 
the  earlier  literature  on  thyroid  transplantation  where, 
as  in  the  dog,  the  parathyroids  are  included  in  the 
thyroid  lobes  and  transplantation  of  the  latter  glands 
included  the  former.  Proof  of  this  is  to  be  drawn 
from  the  functional  results  that  followed  the  removal 
of  the  transplants,  where,  in  many  instances  death 
with  more  or  less  severe  manifestations  of  tetany 
followed  the  removal  of  the  transplanted  tissue.  As 
some  of  this  work  was  done  before  we  knew  about 
the  relation  of  the  parathyroid  glands  to  tetany  there 
was  no  proper  interpretation  of  the  results  until 
after  the  work  of  Gley  on  the  parathyroid  glands 
appeared. 

Kocher  (1883)  recommended  thyroid  transplan- 
tation to  prevent  postoperative  tetany  as  well  as 
cachexia    strumipriva,    myxcedema   and   cretinism. 

Eiselsberg  (1892)  transplanted  one  thyroid  lobe 
between  the  peritoneum  and  fascia  in  four  cats  and 
later  (five  days  to  one  month),  extirpated  the  re- 
maining thyroid  lobe.  The  animal  showed  no  symp- 
toms following  such  procedure,  and  in  from  one  to 
three  months  after  the  operation  the  implanted  thy- 


PARATHYROID    THERAPY  353 

roid  was  removed.  As  a  result  of  the  removal  of 
the  transplant  the  animals  quickly  died  with  severe 
tetanic  symptoms.  Histologic  sections  of  the  re- 
moved tissue  showed  it  to  have  the  appearance  of 
normal  thyroid.  While  there  is  no  mention  of  para- 
thyroid tissue,  we  must  assume  from  the  results  of 
the  experiment  that  sufficient  parathyroid  to  pre- 
serve the  animal  from  tetany  was  transplanted  with 
the  thyroid  and  persisted  up  to  the  time  of  its  re- 
moval. 

Enderlen  (1898)  in  his  transplantation  experi- 
ments in  dogs  and  cats  took  into  account  the  para- 
thyroids and  stated  that  they  persist  after  trans- 
plantation even  better  than  thyroid  tissue. 

Payr  extirpated  the  thyroid  lobes  of  cats  and  dogs 
and  transplanted  the  same  into  the  spleen.  In  some 
instances  one  lobe  was  transplanted  and  the  remain- 
ing lobe  removed  ten  or  twelve  days  later.  In  other 
cases  the  whole  gland  was  removed  from  the  neck 
and  placed  in  the  spleen  at  the  first  sitting,  and 
twenty  or  thirty  days  later  the  other  lobe  was  trans- 
planted into  the  spleen  in  a  different  place.  As  far 
as  the  functional  results  of  these  experiments  went, 
the  animals  in  general  exhibited  no  symptoms  even 
after  many  months.  After  extirpation  of  the  spleen, 
however,  the  animals  quickly  died,  usually  with 
symptoms  of  tetany. 

Examination  of  the  transplant  showed  the  im- 
planted thyroid  to  be  reduced  to  one-fourth  or  one- 
third  its  normal  size.  The  central  necrosis  was  less 
marked  than  in  other  reported  transplants  and  re- 
generation processes  were  prominent,  so  that  a  pic- 
ture  of  normal  colloid-forming  thyroid  tissue  was 


354  PARATHYROID    GLANDS 

present.  Payr  concluded  that  a  gland  with  an  inner 
secretion  was  better  adapted  to  transplantation  than 
other  functional  tissue. 

Christiani  reported  the  persistence  of  parathyroids 
transplanted  into  a  cat.  After  five  years  they  were 
found  practically  unchanged.  This  author,  together 
with  Ferrari,  was  one  of  the  first  to  transplant  thy- 
roid and  parathyroid  and  consider  each  separately. 

Camus  seems  to  be  the  first  to  attempt  the  trans- 
plantation of  parathyroid  glands  only.  The  site 
chosen  by  this  author  was  the  rabbit's  ear.  His  re- 
sults were  not  satisfactory  and  he  stated  that  the 
transplanted  glandules  showed  an  early  atrophy. 

Walbaum  attempted  to  transplant  the  parathy- 
roids into  the  serosa  of  the  stomach  of  a  cat,  but  with- 
out success.  After  transplantation  of  the  superior 
glandules,  he  destroyed  the  remaining  glandules  and 
the  animals  promptly  died  from  tetany  or  went 
gradually  into  a  state  of  chronic  cachexia  from  which 
they  died. 

Biedl  reported  two  cases  of  successful  auto-trans- 
plantation of  parathyroids  into  the  dog's  spleen.  In 
the  first  animal,  thirteen  days  after  the  transplanta- 
tion, the  thyroid  and  remaining  parathyroids  were 
removed  without  the  dog  exhibiting  any  symptoms 
of  tetany.  The  second  dog,  however,  developed 
tetany  four  days  after  the  thyroid  and  remaining 
parathyroid  removal.  The  symptoms  were  con- 
trolled by  parathyroid  feeding  and  the  dog  recovered. 
In  two  other  animals,  foreign  parathyroids  were 
planted  in  the  spleen  with  removal  of  the  normal 
glands  sometime  after  the  transplantation  and  a  year 
later  the  author  reported  survival  of  one  animal  with 


PARATHYROID    THERAPY  355 

no  signs  of  tetany  for  seven  months,  but  death  from 
cachexia  thyropriva.  The  two  intact  parathy- 
roids were  found  in  the  spleen.  The  second  dog  was 
still  alive,  the  transplanted  parathyroids  being  ap- 
parently sufficient.  Halsted  has  criticised  this 
work  of  Biedl's  as  he  had  been  unable  to  get  similar 
results  by  "foreign"  transplants  or  without  creating 
a  parathyroid  deficiency  before  transplanting.  More- 
over, functional  proof  is  lacking  in  these  experi- 
ments, as  transplants  were  not  excised  during  life 
to  see  if  their  removal  would  cause  death  from  tetany. 

Pool,  following  the  technic  of  Payr,  has  tried 
transplantation  without  success.  In  eight  dogs,  six- 
teen rabbit  parathyroids  were  grafted  into  the  spleen. 
In  four  dogs,  ten  dog  parathyroids  were  transplanted 
in  the  same  manner.  These  transplants  were  made 
from  eight  to  twenty-eight  days  before  removing  the 
normal  parathyroids.  In  none  of  these  cases  did 
the  transplants  influence  at  all  the  usual  develop- 
ment of  tetany  following  parathyroid  removal  and 
all  the  dogs  died  with  acute  tetanic  symptoms. 

Pepere  states  that  after  removal  of  the  external 
parathyroids  in  the  rabbit  (which  brought  on  symp- 
toms of  parathyroid  insufficiency),  he  was  able  to 
control  symptoms  by  implantation  of  one  or  several 
parathyroid  glandules.  However,  the  graft  was 
soon  absorbed.  Its  effect  was  sufficient,  however,  to 
tide  over  a  parathyroid  deficiency  until  certain  ac- 
cessory parathyroid  tissue  (which  this  author  de- 
scribes), had  had  time  to  hypertrophy  and  keep  the 
animal  in  normal  condition. 

Capebelle  removed  transplanted  thyroid  from  a  dog 
two  hundred  and  forty-five  days  after  operation,  and 


356  PARATHYROID   GLANDS 

found  it  in  good  condition.  The  animal,  however, 
died  of  tetany  following  its  removal,  showing  that 
parathyroid  must  have  been  transplanted  with  the 
thyroid  and  preserved  its  function. 

Pfeiffer  and  Mayer  have  successfully  transplanted 
the  parathyroids  in  two  six  weeks'  old  puppies. 
They  state  that  they  prefer  dogs  to  rats. for  this  work 
because  the  outer  parathyroids  are  well  separated 
from  the  thyroid  in  the  former  and  because  dogs 
manifest  tetany  much  more  acutely  than  rats.  These 
authors  transplanted  one  outer  parathyroid  gland 
into  the  abdominal  wall  between  the  muscle  and 
peritoneum  and  extirpated  the  thyroid  lobe  and 
inner  parathyroid  on  that  side.  At  the  end  of  a 
week  they  carried  out  the  same  operation  on  the 
other  side.  Neither  of  the  dogs  operated  upon  ex- 
hibited tetany  following  such  procedure ;  and  at  the 
end  of  six  weeks  a  functional  test  of  the  efficacy  of 
the  transplants  was  made.  Following  the  excision 
of  the  transplants  both  animals  succumbed  to  death 
in  acute  tetany,  the  symptoms  of  which  appeared 
two  days  after  excision  of  the  transplanted  tissue. 
A  similar  procedure  carried  out  in  a  third  dog  (six 
months  old),  did  not  result  successfully.  The  ani- 
mal developed  tetany  soon  after  the  transplantation 
and  despite  the  feeding  of  thyroid  tablets  died  in 
cachectic  condition  in  about  a  week.  Histologic  ex- 
amination of  the  transplanted  tissue  in  this  case 
showed  it  to  have  undergone  necrosis. 

Leischner,  who  was  the  first  to  establish  the  func- 
tional proof  of  parathyroid  transplantation,  carried 
out  his  experiments  on  eighty  rats.  In  about  ten 
per  cent  of  these  animals  he  was  able  to  transplant 


PARATHYROID    THERAPY  357 

parathyroids  and  have  them  maintain  their  function. 
He  chose  to  place  the  parathyroids  between  the 
peritoneum  and  the  rectus  abdominis,  or  in  the 
muscle  itself.  Such  transplants  were  made  suc- 
cessfully in  four  rats  in  which  both  parathyroids  were 
transplanted  with  an  interval  of  ten  days  to  a  month 
between  the  operations.  No  signs  of  tetany  ap- 
peared. From  three  to  six  weeks  later  the  portion 
of  the  wall  containing  the  transplanted  glandules 
was  extirpated  and  tetany  followed  the  removal.  In 
four  other  rats  both  parathyroids  were  transplanted 
at  the  same  time  and  tetany  resulted,  but  after  a 
time  it  ceased.  Then,  in  three  or  four  weeks,  the 
tissue  containing  the  transplant  was  removed  and 
a  new  attack  of  tetany  promptly  occurred. 

Halsted's  transplantation  experiments,  carried  on 
for  a  period  of  two  years,  show  sixty  per  cent  of  suc- 
cessful results  in  autotransplantations  with  created 
deficiency.  The  negative  results  are  of  value  in 
bringing  out  the  fact  that  a  parathyroid  deficiency 
must  be  created  by  the  removal  of  at  least  two  glands 
before  successful  transplantation  can  be  expected. 
It  is  to  be  noted  that  auto-transplantations  were  the 
only  ones  giving  successful  results.  Isotransplan- 
tation  which  was  tried  on  thirty-eight  dogs,  was 
uniformly  unsuccessful.  The  isotransplantations 
were  made  into  the  thyroid,  spleen,  and  behind  the 
rectus  abdominis  but  the  isograft  did  not  live  in  a 
single  instance. 

In  the  first  series  of  autotransplantations  by  Hal- 
sted,  five  auto-grafts  into  the  thyroid  of  three  dogs 
gave  two  successful  results;  eight  auto-grafts  into 
the  spleen  of  three  dogs  gave  only  one  successful  re- 


358 


PARATHYROID    GLANDS 


suit.  Functional  proof  of  the  success  of  these  trans- 
plantations was  not  attempted,  but  microscopically 
and  macroscopically  the  graft  appeared   successful. 


Fig.  77.     Transplanted  parathyroid  glandule  in  the  tibia  of  a  dog. 


In  the  second  series,  auto-transplantation  was  made 
behind  the  rectus  abdominis  muscle.  Out  of  eighteen 
such  transplantations  in  twelve  dogs,  seven  para  thy- 


PARATHYROID    THERAPY  359 

roids  were  absorbed  or  necrotic;  five  to  seven  lived 
and  performed  their  function.  In  two  of  the  dogs 
the  functional  test  was  made.  Both  these  dogs 
died  in  tetany  after  the  removal  of  the  sustaining 
auto-graft.  Two  other  dogs  were  alive  and  well  after 
nine  and  ten  months  respectively,  sustained  appar- 
ently by  a  single  transplanted  parathyroid  gland 
only.  Both  these  dogs  developed  myxcedema,  (the 
thyroids  were  removed  with  the  parathyroids)  with 
eczema  and  some  falling  of  the  hair. 

In  some  of  Halsted's  experiments,  when  too  sud- 
den a  deficiency  was  created,  a  beginning  tetany  was 
tided  over  by  the  administration  of  calcium  salts, 
until  the  transplanted  grafts  acquired  a  circulation 
sufficient  for  them  to  exercise  their  function. 

Eiselsberg  has  reported  a  case  in  which  a  parathy- 
roid was  transplanted  in  a  human  subject.  The 
patient  was  a  woman,  forty-two  years  old,  who  for 
many  years  had  suffered  from  a  fairly  severe  tetany 
which  followed  total  thyroid  extirpation.  She  had 
many  times  been  in  the  clinic  during  goitre  opera- 
tions and  at  last  a  favorable  case  was  operated  upon 
and  a  gland  was  transplanted;  this  was  apparently 
followed  by  good  results.  Von  Eiselsberg  believes 
that  removal  of  a  parathyroid  for  this  purpose  is 
permissible  only  when  a  cyst  is  taken  out  of  one  lobe 
of  the  thyroid  and  the  remainder  of  the  organ  appears 
normal  so  that  one  can  say  with  some  certainty  that 
three  parathyroids  are  left  intact.  Garre  has  also 
reported  good  results  following  the  transplantation  of 
parathyroid  into  the  tibia  in  a  case  of  chronic  tetany. 

The   recent   thyroid   transplantations    of   Kocher 
must  be  taken  into  accoimt  in  considering  the  ques- 


360  PARATHYROID    GLANDS 

tion  of  parathyroid  transplantation.  Kocher's  trans- 
plantations are  made  into  the  bone  marrow  of  the 
tibia,  this  bone  lending  itself  best  to  such  an  opera- 
tion. The  process  is  carried  out  in  two  stages.  In 
the  first  stage  the  marrow  cavity  is  opened,  a  small 
pocket  formed,  and  a  silver  ball  about  lxl .  5  cm.  in- 
troduced. The  wound  is  then  closed.  After  two 
or  three  days  it  is  reopened,  the  ball  removed  and 
the  fresh  gland  tissue  implanted  into  the  cavity  thus 
formed.  In  this  way  the  author  avoids  extensive 
hemorrhage  about  the  implanted  tissue,  a  layer  of 
granulations  having  formed  about  the  ball.  Experi- 
mentally, Kocher  found  that  thyroid  tissue  thus 
transplanted  in  dogs  proved  efficient  for  the  main- 
tenance of  life.  If  the  bone  containing  the  trans- 
planted tissue  was  resected,  the  animal  quickly  died 
with  acute  symptoms  of  tetany. 

To  be  especially  noted  is  the  fact  that  in  these  ex- 
periments of  Kocher  there  were  no  acute  symp- 
toms of  tetany  following  the  implantation,  although 
thyroid  alone  was  grafted  and  all  parathyroids  re- 
moved, but  as  soon  as  the  bone  containing  the  trans- 
planted portion  of  thyroid  was  removed  acute  tetany 
leading  to  death  resulted.  Kocher  considers  the 
question  of  parathyroid  tissue  having  been  trans- 
planted with  the  thyroid  in  his  case,  but  says  that 
histologically  nothing  but  thyroid  tissue  was  found 
in  the  bone. 

Thompson,  Leighton  and  S warts  have  tried  various 
situations  for  placing  transplanted  glandules.  The 
method  of  Kocher  for  transplantation  of  parathy- 
roid into  the  shaft  of  the  tibia  has  been  attempted,  as 
well  as  transplantation  of  thyroid  alone  in  this  situ- 


PLATE  XL 


PARATHYROID  GLANDULE  (WITH  BLOOD  VESSEL),  FORTY  DAYS  AFTER 
TRANSPLANTATION  INTO  THE  NECK  OF  A  DOG.  THE  ANIMAL  WAS  SUSTAINED 
BY  THIS  GLANDULE,  AS  WAS  SHOWN  BY  DEATH  IN  TETANY  TWENTY-FOUR 
HOURS    AFTER   ITS  EXCISION. 


PARATHYROID    THERAPY  36 

at  ion,  as  the  authors  could  not  understand  why  in 
the  case  Kocher  reports  he  should  have  obtained  the 
same  results,  including  the  functional  test,  for  thy- 
roid, that  numerous  experiments  have  shown  con- 
clusively to  depend  on  parathyroid  transplantation. 

These  authors  found  that  dogs  which  had  been 
submitted  to  the  tibia  operation  did  not  develop 
tetany  although  all  parathyroids  were  removed,  or 
transplanted  parathyroid  had  been  shown  micro- 
scopically to  have  undergone  necrosis.  The  dogs  did 
die  finally,  however,  from  cachexia.  Moreover,  in 
two  animals  from  which  the  parathyroids  had  been 
removed  the  tibia  operation  markedly  influenced  the 
tetany  parathyropriva  even  after  the  dog  had  de- 
veloped severe  symptoms. 

It  would  seem,  then,  that  there  might  be  some 
connection  between  the  traumatic  injury  of  bone  and 
the  prevention  of  tetany.  In  Kocher's  case  this 
seemed  to  be  disproved  by  the  statement  that  when, 
in  his  dog,  the  transplanted  thyroid  (which  was 
microscopically  free  from  parathyroid) ,  was  removed 
death  in  tetany  resulted.  This,  if  it  were  true  in  a 
number  of  instances,  would  be  indeed  difficult  to 
explain,  for  the  presence  of  thyroid  tissue  has  never  in 
the  least  influenced  the  fatal  tetanic  results  of  para- 
thyroid removal  which  has  been  practiced  so  many 
times. 

In  the  case  of  Thompson,  Leighton  and  Swarts, 
the  removal  of  the  transplanted  thyroid  had  no  effect 
whatever  in  the  experiment.  It  is  to  be  noted,  how- 
ever, that  these  dogs  in  which  a  bone  transplanta- 
tion is  practiced,  although  escaping  a  fatal  tetany, 
usually  die  in  chronic  cachexia.    These  experiments, 


362  PARATHYROID    GLANDS 

therefore,  influence  in  no  way  the  well-established 
fact  that  the  parathyroid  glandules  are  vital  organs, 
but  they  suggest  that  the  bone  operation  may  serve 
as  a  factor  in  checking  the  tetany  which  is  usually 
the  most  prominent  symptom  of  parathyroprivic 
death. 

One  of  the  most  recent  contributions  to  the  tem- 
porary cure  of  tetany  after  loss  of  the  parathyroid 
glandules  has  been  made  by  Isaac  Ott.  This  author, 
who  used .  cats  chiefly  for  his  experiments,  found 
that  the  tetany  following  complete  parathyroid- 
ectomy in  these  animals  could  be  controlled  by  the 
administration  of  pituitary  extract.  When  ten  to 
twenty  grains  of  this  drug  rubbed  up  with  distilled 
water  was  injected  there  was  a  replacement  of  the 
tremor  by  steadiness  in  about  three  hours.  Tetany 
did  not  reappear  for  twenty-four  hours.  In  compar- 
ing the  effects  of  calcium  lactate  and  pituitary  ex- 
tract in  tetany,  it  is  to  be  noted  that  while  the  action 
of  the  former  is  quicker,  the  action  of  the  latter  drug 
seems  to  continue  longer. 


From  all  that  has  gone  before  we  find  that  tetany, 
although  it  isja  dramatic  event  in  connection  with 
parathyreoprivic  death,  is  but  a  symptom,  that 
usually,  but  not  necessarily,  accompanies  loss  of 
these  bodies.  We  can  control  tetany  after  parathy- 
roidectomy, but  we  cannot  maintain  life  for  any 
considerable  time  without  the  parathyroid  gland- 
ules. Deprived  of  these  vital  organs  an  animal  or 
an  individual  will  die;  acutely  and  convulsively  if 
the  deprivation  is  sudden,  slowly  and  quietly  if  the 


PARATHYROID    THERAPY  363 

loss  is  more  slowly  brought  about.  While  in  the 
past  investigation  has  centered  itself,  naturally, 
upon  the  more  striking  phenomena  of  complete 
parathyroidectomy,  it  is  possible  that  future  work 
may  give  us  a  better  understanding  of  the  nature 
of  the  changes  incident  to  the  gradual  loss  of  func- 
tion of  the  parathyroid  glandules. 


PARATHYROID  LITERATURE 


Alquier,  L.— Gazette  d.  Hop.,  1903,  June  13,  20;  idem,  1906,  No.  132, 

p.  1527;  Compt.  Rend.  Soc.  de  Biol.,  1906,  Oct.,  p.  302. 
Alquier  and  Theunveny — Compt.  Rend.  Soc.  de  Biol.,  1907,  t.  63,  p. 

397;  idem,  1909,  t.  66,  p.  217. 
Anderson,  O.  A. — Arch.  f.  Anat.  und  Physiol.,  Anat.  Abth.,  1894,  p. 

177. 
Askanazy,  M.^Arb.  a.  d.  Pathol.  Inst.,  Tubingen,  1904,  bd.  4,  heft  3, 

p.  398. 

Baber,   E.    C— Phil.  Tr.  Royal  Soc.  of  London,  1876,  vol.  166;  idem, 

1881,  No.  209,  p.  279. 
Bayon,  P.  C  — Wurzburg,  1903. 

Beebe,  S.  P.— Proc.  Soc.  for  Exp.  Biol,  and  Med.,  1907,  p.  64. 
Benjamins,  C.  E  —  Ziegler's  Beitrage,  bd.  31,  1902,  p.  143. 
Berard,  L.  and  Alamartine — Compt.  Rend.  Soc.  de  Biol.,  1909;  t.  66,  p. 

619;  Lyon  Chir.,  1909,  May,  p.  72. 
Berkeley,  W.  N.— Med.  News,  1905,  Dec.  2. 

Berkeley  and  Beebe— Jour,  of  Med.  Research,  1909,  vol.  20,  p.  113. 
Biedl,  A. — Wiener  Klin.  Wochenschr.,  1907,  p.  615. 
Blum,  F. — Kongress  f.  Innere  Med.,  Munchen,  1906,  p.  183. 
Blumreich,  L.  and  Jacoby,  M. — Berl.  Klin.  Wochenschr.,  1896,  No.  15, 

p.  327;  Pfluger's  Archiv.,  1896,  bd.  64,  p.  1. 
Botcheff — Thesis,  Geneva,  1905. 

Bramwell,  B. — Brit.  Med.  Jour.,  1895,  June  1,  p.  1196. 
Brissaud — Presse  Med.,  1898. 

Cadeac,  C.  and  Guinard,  L.— Compt.  Rend.  Soc.  de  Biol.,  1894,  June, 

pp.  468,  508,  509. 
Camus— Compt.  Rend.  Soc.  de  Biol.,  1905,  p.  321. 
Canal,  A.— Gazz.  d.  Osp.  e  delle  Clin.,  1909,  vol.  30,  No.  89. 
Capobianco,  Fr.— Riforma  Med.,  1895;  Internat.  Monatschr.  f.  Anat. 

und  Physiol.,  1894,  p.  515. 
Capobianco  and  Mazziotti — Gior.  Internaz.  d.  Sc.  Med.,  1899,  vol.  21. 
Carnot  and  Delion— Bull,  de  la  Soc.  de  Biol.,  1905,  p.  321. 
Caro,  L.— Mitt.  a.  d.  Grenzgeb.  d.  Med.  und  Chir.,  1907. 
Carter,  W.  S.— Texas  State  Jour.,  1907,  vol.  3,  p.  229. 
Castelvi—  Riv.  di  Med.  y  Cir.  Prat.,  Madrid,  1903. 
Chantemesse  and  Marie— Soc.  Med.  d.   Hop.,   1893,   vol.   10,   p.   202; 

Semaine  Med.,  1893,  p.  130. 
Chdnu,  J.  and  Morel,  A.— Compt.  Rend.  Soc.  de  Biol.,    1904,  vol.  56, 

p.  77. 
Christens,  D.— Hosp.-Tid.,  1904,  No.  39. 


366  PARATHYROID  LITERATURE 

Christian!,  H.— Compt.  Rend.  Soc.  de  Biol.,  1892,  Oct.,  p.  798;  idem, 

1894,  Nov.,  p.  716;  Arch,  de  Physiol.  Norm,  et  Pathol.,  1893,  pp. 

39,  164,  279;  Jour,  de  Physiol,  et  Pathol.  Gin.,  1905,  vol.  7,  p.  261. 
Christiani,  H.  and  Ferrari,  E. — Compt.  Rend.  Soc.  de  Biol.,  1897,  Oct. 
Chvostek — Wiener  Klin.  Wochenschr.,  1905,  p.  969;  idem,  1907,  pp. 

487,  625. 
Cimdrom — Lo  Sperimentale,  1907,  Sept.— Oct. 
Civalleri,  A.— Policlinics,  1902,  No.  3. 
Claude,  H.  and  Schmiergeld,  A. — Compt.  Rend.  Soc.  de  Biol.,  1908, 

vol.  65,  pp.  80,  139;  idem,  1909,  vol.  66,  p.  131. 
Conradi  and  Marchetti — Riv.  di  Patol.,  Nerv.  e  Ment.,  1904,  p.  255. 
Cotoni,  L.— Rev.  de  Med.,  1909,  vol.  29,  No.  8. 

DaCosta,  J.  C— Surg.  Gyn.  and  Obst.,  1909,  p.  32. 
Doyon— Jour,  de  Physiol,  et  Pathol.  Gen.,  1907,  vol.  9,  p.  457. 
Doyon  and  Jouty — Compt.  Rend.  Soc.  de  Biol.,  1904. 
Doyon  and  Karefe — Compt.  Rend.  Soc.  de  Biol.,  1904. 

Ebner,  V. — Koelliker's  Handb.  der  Gewebelehre  des  Menschen,  1902, 

bd.  3,  p.  325. 
Edmunds,  W.— Jour.  Physiol.,  1895;  Brit.  Med.  Jour.,  1901,  2,  p.'773; 

Jour,  of  Pathol,  and  Bact.,  1896,  1899,  1902;  Lancet,  1908,  vol.  1, 

p.  811. 
Eggers— Tr.  Chicago  Pathol.  Soc,  1907, 'p.  102. 
Eiselsberg,  von — Langenbeck's  Arch.,  1894,  bd.  48,  p.  489;  Deutsche 

Ztschr.  f.  Chir.,  1901,  No.  38;  Wiener  Klin.  Wochenschr.,  1906, 

Nos.  25,  26;  idem,  1907,  No.  21. 
Enderlen— Mitt,  a.  d.  Grenzgeb.  d.  Med.  und  Chir.,  1898,  bd.  3,  p.  474. 
Erdheim — Wiener  Klin.  Wochenschr.,  1901,  No.  41;  Ziegler's  Beitrage, 

1903,  bd.  33,  p.  158;  idem,  1904,  bd.  35,  p.  366;  Ztschr.  f.  d.  Ges. 

Heilk.,   1904,  bd.  25;  Kongress  f.  Innere  Med.,  Munchen,   1906, 

April;  K.  K.  Ges.  der  Aerzte,  Wien,  1906,  June  1,  vol.  1;  Wiener 

Klin.  Wochenschr.,  1906,  pp.  716,  817;  Mitt.  a.  d.  Grenzgeb.  d. 

Med.  und  Chir.,  1906,  bd.  16,  hefte  4,  5;  Anatomischer  Anzeiger, 

1906,  bd.  29,  p.  609. 
Escherich — Mitt.  d.  Ges.  f.  Innere  Med.  uhd  Kinderheilk.,  1906,  Nov.; 

Wiener  Klin.  Wochenschr.,  1907,  p.  614. 
Esterbrook — Lancet,  1898,  vol.  2,  p.  546. 

Estes,  W.  L. — Johns  Hopkins  Hosp.  Bull.,  1907,  vol.  18,  p.  335. 
Estes,  W.  L.  and  Cecil,  A.  B. — Johns  Hopkins  Hosp.  Bull.,  1907,  vol. 

18,  p.  331. 

Fiori — Arch,  per  le  Sc.  Med.,  Torino,  1905,  vol.  29,  p.  428. 

Flint — Amer.  Jour,  of  Anatomy,  1904—5,  vol.  4,  p.  77. 

Forsyth,  D.— Lancet,    1907,    p.  154;  Brit.  Med.  Jour.,  1907,  pp.  141, 

372,  1177. 
Fraina — Pavia,  1905,  ref.  Guizzetti. 


PARATHYROID    LITERATURE  367 

Frankl-Hochwart — Die  Tetanie,  Nothnagel's  Spez.  Pathol,  und  Ther., 
1891;  Deutsche  Klinik,  1905,  lieferung  151,  p.  933;  Wiener  Med. 
Wochenschr.,  1906,  p.  309;  Neurolog.  Centralb.,   1906,  Nos.  14,  15. 

Fromme,  V.— Wiener  Klin.  Wochenschr.,  1906,  p.  818;  Monatsschr.  f. 
Geburtsh.  und  Gyn.,  1906,  bd.  24,  heft  6. 

Fusari— Torino,  1899. 

Gamier— Thesis,  Paris,  1899;  Gazette  d.  Hop.,  1899. 

GarrS— Ztschr.  f.  Chir.,  1908,  No.  35,  beilage,  p.  31. 

Geis,  N.  P.— Ann.  of  Surg.,  1908,  p.  523. 

Getzowa,  S.— Virchow's  Arch.,  1907,  vol.  188,  p.  181. 

Ginsburg— Univ.  of  Penn.  Med.  Bull.,  1908,  Jan. 

Gley,  E.  A.— Compt.  Rend.  Soc.  de  Biol.,  1891,  Dec.  19,  p.  843;  idem, 

1892,  July  16,  p.  666;  idem,  1893,  Feb.  25,  p.  217;  idem,  1893, 

July,  p.  691;  idem,  1897,  Jan.  9,  p.  18;  idem,  1897,  Jan.  16,  p.  46; 

Arch,  de  Physiol.  Norm,  et  Pathol.,  1892,  1893;  Brit.  Med.  Jour., 

1901,  2,  p.  771. 
Gley,  E.  A.  and  Phisalix— Compt.  Rend.  Soc.  de  Biol.,  1893,  Feb.  25, 

p.  219. 
Goris — -Ann.  de  lTnat.  Chir.  de  Brux.,  1906,  vol.  13,  p.  64. 
Gozzi,  C— Boll.  Soc.  Med.  y  Cir.  di  Pavia,  1907,  vol.  21,  p.  310;  Gazz. 

Med.  Ital.,  Torino,  1907,  vol.  58,  p.  461. 
Groschuff,  K. — Anatom.  Anzeiger,  1896,  bd.  12,  p.  497. 
Gross,  E. — Munchener  Med.  Wochenschr.,  1906,  p.  1616. 
Guizzetti,   P. — Centralb.  f.   Allgem.   Pathol,  und  Pathol  Anat.,   1907, 

No.  3. 

Halsted,  W.  S—  Amer.  Jour.  Med.  Sci.,  1907,  vol.  134,  p.  1;  Jour,  of 

Exper.  Med.,  1909,  vol.  11,  p.  175. 
Halsted  and  Evans— Ann.  of  Surg.,  1907,  p.  489. 

Harvier,  P.  and  Morel,  L. — Compt.  Rend.  Soc.  de  Biol.,  1909,  t.  66. 
Haskovec,  L. — Ref.  Schmidt's  Jahrbiicher,  bd.  292,  p.  161. 
Hecker — Ges.  f.  Natur  und  Heilkunde  zu  Dresden,   1906,   Dec.   15; 

ref.  Munchener  Med.  Wochenschr.,  1907,  p.  493. 
Hofmeister — Fortschritte  der  Med.,   1892;  Brun's  Beitrage  zur  Klin. 

Chir.,  1894,  bd.  11;  Deutsche  Med.  Wochenschr.,  1896. 
Huerthle,  K.— Arch.  f.  d.  Ges.  Physiol.,  1894,  bd.  56. 
Hulst,  J.  P.  L.— Centralb.  f.  Allgem.  Pathol,  und  Pathol.  Anat.,  1905, 

bd.  16,  p.  103. 
Humphry — Lancet,  1905,  vol.  2,  p.  1390. 
Hutchinson,  R. — Jour,  of  Physiol.,  1898. 

Iselin,  H.— Deutsche  Ztschr.  f.  Chir.,  1908,  bd.  93,  pp.  397,  494. 
Ivanoff — Thesis,  Geneva,  1905. 

Jacoby,  M. — Inaug.-Diss.,  Berlin,  1895;  Anat.  Anzeiger,  1896,  bd.  12, 
p.  152. 


368  PARATHYROID    LITERATURE 

Jeandelize,  P.— Thesis,  Nancy,  1902;  Paris,  1903. 
Jouty — Thesis,  Lyon,  1903. 

Kaydi — Arch,  f .  Anat.  und  Physiol.,  1878. 

Kenderdjy — Clinique,  Paris,  1908,  vol.  3,  p.  363. 

Kinnicutt — Amer.  Jour.  Med.  Sc,  1909,  vol.  138. 

Kishi,  K.— Virchow's  Arch.,  1904,  bd.  176,  p.  260. 

Kocher,  T.— Arch.  f.  Klin.  Chir.,  1883,  bd.  29,  p.  254;  idem,  1908,  bd. 

87,  No.  1. 
Kocher-Kraus — Miinchener  Med.  Wochenschr.,  1906.  No.  18. 
Kohn,  A.— Arch.  f.  Mikr.  Anat.,  1895,  bd.  44,  p.  366;  idem,  1897,  bd. 

48,  p.  398;  Ergebnisse  der  Anat.  und  Entwick.,  1899,  bd.  9. 
Kollmann,  J. — Lehrbuch  der  Entwicklungsgeschichte  des  Menschen, 

1898. 
Konigstein,  H. — Wiener  Klin.  Wochenschr.,  1904,  p.  636;  idem,  1906, 

p.   778;  idem,    1906,   p.    1532;   Mitt.   d.  Ges.  f.  Innere   Med.  und 

Kinderheilk.,  1906,  Dec.  6,  p.  191. 
Kursteiner — Anat.  Hefte  von  Merkel  und  Bonnet,  1898,  bd.  9,  heft  3; 

idem,  1899,  bd.  11. 

Lange,  M.— Ztschr.  f.  Geburtsh.  und  Gyn.,  1899,  bd.  40,  p.  34. 

Lanz — Volkmann's  Vortrage,  1894,  No.  87;  Mitt.  a.  d.  Klinik  und  Med. 

Institut,  Schweiz,  1895. 
Leischner,  K. — Wiener  Klin.  Wochenschr.,  1907,  p.  645. 
Leopold,  J.  and  Reuss,  A. — Wiener  Klin.  Wochenschr.,  1908,  No.  35. 
Livini — Monitore  Zool.  Ital.,  Florence,  1904,  p.  33. 
Lowenthal  and  Wiebrecht — Deutsche  Ztschr,.  f.  Nervenheilk.,  1906,  bd. 

31,  heft  5,  p.  415. 
Lundborg — Deutsche  Ztschr.  f.  Nervenheilk.,  1904,  bd.  27,  p.  217. 
Lusena — Fisiopathologia  dell'Apparecchio  Tiro-Paratiroideo,  Florence, 

1899. 

MacCallum,  W.  G.— Med.  News,  1903,  Oct.  31;  Johns  Hopkins  Hosp. 

Bull.,  1905,  vol.  11;  Centralb.  f.  Allgem.  Pathol,  und  Pathol.  Anat., 

1905,  bd.  76,  p.  385;  Brit.  Med.  Jour.,  1906,  Nov.  10,  p.  1282. 
MacCallum  and  Davidson — Med.  News,  1905,  p.  625. 
MacCallum  and  Voegtlin — Johns  Hopkins  Hosp.  Bull.,  1908,  vol.  19, 

p.  91;  Jour,  of  Exper.  Med.,  1909,  vol.  11,  No.  1,  p.  118. 
MacCallum,  Thomson  and  Murphy — Johns  Hopkins  Hosp.  Bull.,  1907, 

vol.  18,  p.  333. 
Manca,  P. — Lo  Sperimentale,  1905,  vol.  6,  p.  835. 
Mant  and  Shaw — Clin.  Soc  of  London,  1906,  Jan.  26. 
Maresh — Ztschr.  f.  Heilkunde,  1898. 
Marinesco,  G. — Semaine  Medicale,  1905,  p.  289. 
Maselung — Arch.  f.  Klin.  Chir.,  1879,  vol.  24. 
Mattauschek,  E. — Wiener  Klin.  Wochenschr.,  1907,  No.  16. 


PARATHYROID    LITERATURE  369 

Maurer,  F. — Hertwig's  Handbuch  d.  Vergl.  und  Exp.  Entwick.,  1902, 

bd.  2,  abt.  1. 
Mayo,  C.  H.— Surg.,  Gyn.  and  Obst.,  1907, /vol.  5. 
Meuron,  P. — Diss.,  Geneva,  1886. 
Michand,  L.— Virchow's  Arch.,  1908,  bd.  191,  p.  63. 
Michelazzi — Ref.  Miinchener  Med.  Wochenschr.,  1907,  p.  397. 
Mironesco — Compt.  Rend.  Soc.  de  Biol.,  1908,  p.  515. 
Mobilio,  C— Arch.  Sci.  d.  r.  Soc.  de  Accad.  Vet.  Ital.,  Torino,  1908. 
Morat  and  Dyon — Traite  de  Physiol. 

Mossaglia,  A. — Gazz.  degli  Osped.,  1906,  Sept.  2,  No.  105. 
Moussu,   G.— Compt.   Rend.   Soc.   de  Biol.,    1892,   Dec;  idem,   1893, 

March,  p.  280;  idem,  1893,  April,  p.  394;  idem,  1897,  Jan.,  p.  294; 

idem,  1898,  July,  p.  44;  idem,  1899,  March,  p.  242;  Thesis,  Paris, 

1897;  Thesis,  Cambridge,  1898. 
Mttller,  L.  R.— Ziegler's  Beitrage,  1896,  bd.  28,  p.  127. 
Mailer,  W. — Jenaische  Ztschr.  f.  Med.  und  Naturw.,  1891,  bd.  6. 
Munk,  H. — Akademie  der  Wissensch.,  1888. 
Murraron — Policlinico  (Section  Practique),  1905,  p.  974. 

Nagel  and  Ross — Ref.  Cotoni. 

Nicolas,  A. — Bull.  Soc.  des  Sc.  de  Nancy,  1893,  p.  13;  Bibliographic 

Anatomique,  vol.  4,  1896. 
Nubiola,  P.  and  Alomar,  J. — Compt.  Rend.  Soc.  de  Biol.,  1909,  t.  66. 

Ott,  I. — Introd.  Lecture,  Phila.,  1909. 

Paladino — Atti  della  Reale  Accad.  Med.  Chir.  di  Napoli,  1893. 
Parhon  and  Urechie — -Ref.  Munchener  Med.  Wochenschr.,  1908,  March. 
Parhon  and  Goldstein: — Compt.  Rend.  Soc.  de  Biol.,  1909,  t.  66. 
Parhon,    Dumitresco   and   Nissipesco — Compt.    Rend.    Soc.    de   Biol., 

1909,  t.  66,  p.  792. 
Payr,  E.— Arch.  f.  Klin.  Chir.,  bd.  80,  p.  780. 
Pepere,  A.— Centralb.  f.  Path.,  1906,  p.  313;  Turin,   1906;  Arch,  de 

Med.  Experim.,  1908,  No.  1. 
Pepere,  A.  and  Saviozzi — Lo  Sperimentale,  1905,  vol.  5. 
Peterson — Virchow's  Arch.,  1903,  bd.  174,  p.  413. 
Peucker,  H.— Ztschr.  f.  Heilk.,  bd.  20,  1899. 
Pfeiffer  and  Mayer — Wiener  Klin.  Wochenschr.,  1908,  No.  22;  Mitt.  a. 

d.  Grenzgeb.  d.  Med.  und  Chir.,  1908,  vol.  18,  p.  379. 
Pineles,  Fr. — Sitzungsb.  der  Kais.  Akad.  der  Wissensch.,  Wien,  1904; 

Wiener  Klin.  Wochenschr.,  1904,' p.  517;  Mitt.  a.  d.  Grenzgeb.  d. 

Med.  und  Chir.,  1904,  bd.  14,  p.  120;  Archiv.  f.  Klin.  Med.,  1906, 

bd.  85,  p.  491;  Wiener  Klin.  Wochenschr.,  1906,  p.  691. 
Pool— Ann.  of  Surg.  ,  1907,  vol.  46,  p.  507. 
Prenant,  A.— Compt.  Rend.  Soc.  de  Biol.,  1893,  May  27,  p.  546;  La 

Cellule,  1894,  vol.  10,  No.  1;  Paris,  1896. 


370  PARATHYROID    LITERATURE 

Quadri,  G.— Gazz.  Med.  Ital.,  1906,  No.  7. 
Quervain,  F.— Virchow's  Arch.,  1893,  bd.  133. 
Quest — Wiener  Klin.  Wochenschr.,  1906,  p.  830. 

Reverdin — Revue  Med.  de  la  Suisse  Roruande,  1882,  1883. 

Rogers  and  Ferguson— -Amer.  Jour.  Med.  Sci.,  1906,  p.  811. 

Rogowitz — Arch,  de  Physiol.  Norm,  et  Pathol.,  1888. 

Rossi,  R. — Soc.  Med.-Chir.,  Modena,  1909,  April. 

Rouxeau,  A. — Compt.  Rend.  Soc.  de  Biol.,  1895,  July,  p.  638;  idem, 

1896,  Nov.,  p.  970;  Arch,  de  Physiol.,  1897,  t.  29,  p.  136. 
Rudinger— Ztschr.  f.  Exp.  Pathol,  und  Ther.,  1898,  bd.  5,  p.  205. 

Sacerdoti — Arch.  f.  Anat.  und  Physiol.,  1894. 

Sandstrom,  J. — Ref.  Schmidt's  Jahrbiicher,  1880,  bd.  187,  p.  114. 

Santi — Internat.  Centralb.  f.  Laryngol.  und  Rhinol.,  1900,  p.  5. 

Schaper,  A. — Arch.  f.  Mikros.  Anat.  und  Entwickl.,  1895,  bd.  44. 

Schiff,  M.— Rev.  Med.  de  la  Suisse  Rornande,  1883,  1884. 

Schilder,  P.— Ziegler's  Beitrage,  1909,  bd.  46,  p.  602. 

Schlesinger,  H. — Neurol.  Centralb.,  1892,  p.  66;  Ztschr.  f.  Klin.  Med., 

1891,  bd.  19,  p.  468. 
Schmorl — Miinchener  Med.  Wochenschr.,  1907,  No.  10,  p.  494;  idem, 

1908,  No.  8,  p.  421. 
Schreiber,  L. — Inaug.-Diss.  and  Arch.  f.  Mikros.  Anat.,  1898. 
Silvestri — Gazz.  diegli  Osp.  e  delle  Clin.,  1909,  vol.  30,  No.  106. 
Simon — These  de  Nancy,   1895;  Revue  Biol,  du  Nord  de  la  France, 

t.  6. 
Soulie,  A. — Jour,  de  l'Anat.  et  Physiol.,  1897,  t.  33. 
Spieler,  Fr. — Mitt.  d.  Ges.  f.  Innere  Med.  und  Kinderh.,  Wien,  1907, 

Feb.  14. 
Stieda — Untersuch.  iiber  die  Entwickl.  der  Glandula  Thymus,  Glandula 

Thyreoidea  und  Glandula  Carotica,  1881. 
Strada,  F. — Pathologica,  1909,  vol.*'l,  p.  423. 

Thaler  and  Adler — Wiener  Med.  Wochenschr.,  1906,  p.  779. 

Thiemisch — Monatsschr.  f.  Kinderh.,  1906,  bd.  5,  p.  165. 

Thompson,.  R.   L. — Jour,   of  Med.   Research,    1906,    vol.    15,   p.   399; 

Amer.  Jour,  of  the  Med.  Sc,  1907,  Oct.;  Centralb.  f.  Pathol.,  1909, 

bd.  20,  p.  916. 
Thompson,  R.  L.  and  Harris,  D.  L. — Jour,  of  Med.  Research,  1908, 

vol.  19,  p.  135. 
Thompson,  R.  L.  and  Leighton,  W.  E. — Jour,  of  Med.  Research,  1908, 

vol.  19,  p.  121. 
Thompson,  R.  L.,  Leighton,  W.  E.  and  Swarts,  J.  L. — Jour,  of  Med. 

Research,  1909,  vol.  21,  p.  125;  idem,  1909,  vol.  21,  p.  135. 
Torretta — Ann.  d.  Mai.  de  1' Oreille,  Paris,  1901,  t.  27. 
Tourneux,  F. — Jour,  de  l'Anat.  et  de  la  Physiol.  Norm,  et  Path.,  1897, 

t.  30. 


PARATHYROID    LITERATURE  371 

Traina,  R.— Bull,  de  Soc.  Med.-Chir.  di  Pa  via,  1905,  p.  197;  Arch,  di 
Biol.,  Florence,  1908,  p.  72. 

Van  Ecke — Arch.  Inter,  de  Phar.,  1897,  p.  81. 

Vassale,  G. — Riv.  Speriment  di  Freniatria,  1897,  vol.  23,  p.  905;  Arch. 

Ital.  de  Biol.,  1898,  vol.  30,  p.  49;  Wiener  Med.  Presse,  1906,  p. 

364;  Soc.  Med.-Chir.  in  Modena,  1906,  July;  ref.  Ann.  di  Ost.  e 

Gin.,  vol.  28,  No.  10. 
Vassale  and  Generali— Riv.  di  Patol.  Nerv.  et  Mentale,  1896;  Arch. 

Ital.  de  Biol.,  1896. 
Verdun— Compt.  Rend.  Soc.  de  Biol.,  1896;  Thesis,  Toulouse,  1897; 

Paris,  1898. 
Verebely — Virchow's  Arch.,  1906,  bd.  187,  p.  80. 
Verstraeten  and  Vanderlinden — Mem.  de  T Acad,  de  Med.  de  Belgique 

1894. 
Vincent  and  Jolly— Jour,  of  Physiol.,  1904,  vol.  32;  idem,  1906,  vol.  34. 
Virchow— Die  Krankhaften  Geschwiilste,  1863,  vol.  3,  p.  13. 

Walbaum— Mit.  a.  d.  Grenzgeb.  d.  Med.  und  Chir.,  1903,  bd.  12,  p.  298. 
Wassertrilling,  E.— Wiener  Med.  Ztg.,  1908,  bd.  53,  pp.  289,  299,  312. 
Weichselbaum— Ver.  Deutscher  Naturf.  und  Aerzte,  Stuttgart,  1906, 

Sept. 
Welsh,  D.  A. — Jour,  of  Anat  and  Physiol.,  1898,  vol.  32. 
Winiwarter,  H.  von.— Scalpel,  Liege,  1907,  vol.  60,  p.  327. 
Winternitz,  M.  C— Johns  Hopkins  Hosp.  Bull.,  1909,  vol.  20,  p.  269. 
Wolfler,  A.— Berlin,  1880. 

Yanasse,  J. — Jahrb.  f.  Kinderh.,  1908,  vol.  67,  Erghft. 

Zanfrognini— Bol.  della  R.  Accad.  Med.  de  Genova,  1905;  Inst.  Ost.- 
Gin.  della  R.  U.  di  Genova,  1905;  Clinica  Ost.,  1905,  vol.  9. 

Zeitschmann,  O.— Mitt.  a.  d.  Grenzgeb,  d.  Med.  und  Chir.,  1908,  bd. 
19,  No.  2. 

Zielinska,  M. — Virchow's  Archiv.,  1894,  bd.  136,  p.  170. 

Zuckerkandl,  E. — Anat.  Hefte,  1902,  abt.  1,  bd.  19. 


REFERENCE  TO  AUTHORITIES. 


Adelmann,  12 

Adler,  329,  330 

Alamartine,  280 

Alquier,  221,  241,   252,   291,    294, 

339 
Anderson,  276 
Apolant,  35 
Askanazy,  274 

Baber,  201 

Babonneix,  255 

Basedow,  12,  38 

Bayon,  301 

Beebe,  86   178,  179.  186,  296.  334, 

342,  347 
Benjamins,    213,    228,    235,    244, 

246,  248,  265,  268,  270,  274,  313 
Berard,  280 
Bergmann,  20 
Berkeley,  211,  215,  251,  252,  292, 

296.  334,  340,  342,  347 
Biedl,  313,  354 
Billroth,  110,  205,  281,  312 
Blum,  300,  301 
Blumreich,  208,  300 
Brandan,  341 
Brissaud,  250 
Bryson,  58 
Burzio,  252 

Cadeac,  287 
Camus,  354 
Cannezzaro,  336 
Capebelle,  355 
Capelle,  71 
Capobianco,  287 
Carnot,  246,  320 
Caro,  301 
Castelio,  252 
Castelvi,  340 
Cecil,  242 
Chantemesse,  235 
Charcot,  12,  38,  46,  85 
Chenu,  242 
Christens,  171,  292 
Christiani,  202,  285,  354 
Chvostek,  318,  320 
Claude,  251,  280 
Coley,  170 
Colzi,  336 
Crile,  91,  95 
Curtis,  188 
DaCosta,  278 


Dana,  252 
D'Ausset,  340 
Davidson,  336,  338 
Delion,  246,  321 
DePaoli,  279 
DeQuervain,  287 
Desmarres,  38,  56 
Donaggio,  291 
Doyon,  289 
Dumitresco,  351 

Ebner,  235 

Edmunds,  247,  287,  288,  291,  338 

Eggers,  246 

Ehrlich,  35 

Eiselsberg,  von,  170,  171,  175,313, 
316,  352,  359 

Enderlen,  171,  353 

Erdheim,  23,  212,  231,  240,  244, 
248,  249,  250,  254,  255,  256, 
257,  265,  268,  269,  271,  292, 
293,  294,  300,  313,  315,  322, 
323,  326,  327,  330,  346 

Escherich,  256,  315,  323,  327 

Esterbrook,  339 

Estes,  222,  242 

Evans,  217,  218 

Ewald,  24 

Fabris,  35,  256 

Fano,  336 

Ferguson,  215 

Ferrari,  354 

Flajani,  11,  38 

Flint,  238 

Forschheimer,  184 

Forsyth,  213,  224,  225,  237,  240, 

245,  249,  263 
Fraenkel,  21,  252 
Frankl-Hochwart,  318,  321,  331 
Frazier,  316 
Frommer,  295 

Gamier,  244,  256 

Garre,  359 

Gautiers,  76 

Geis,  218 

Generali,  285,  286,  328 

Getzowa,  212,  231,  237,  244,  265, 

270 
Ginsburg,  218 
Gley,  203,  208,  221,  242,  247,  283, 

285,  288,  337 


374 


REFERENCE  TO  AUTHORITIES. 


Goldstein,  335 
Goodman,  351 
Goris,  272 
Graefe,  12,  56 
Graves,  12,  38 
Groschuff,  228 
Gross,  332 
Guinard,  287 
Guizzetti,  244,  255 
Gull,  12 
Gunn,  79,  82 

Hagenbach,  263,  294 

Halsted,  28,   188,  218,   316,   328, 

345,  349,  355,  357,  359 
Harnett,  243 
Harris,  212,    216,    260,    263,    265, 

266,    268,  269,    270,    275 
Harvier,  220,  255,  304 
Haskovec,  248 
Hatai,  216 
Hecker,  327 
Hektoen,  21 
Hirsch,  12 

Hofmeister,  208,  284 
Horsley,  251,  281 
Houseman,  von,  71 
Huerthle,  202 
Hulst,  270,  274 
Humphry,  247 

Iselin,  296,  310 

Jackson,  184 
Jacobson,  142,  157,  163 
Jacoby,  von,  208,  300 
Jeandelize,  250,  287,  313,  318 
Jolly,  222,  263,  302,  306,  338 
Jonnesco,  106 
Jouty,  289 

Kareff,  289 

Kassowitz,  327 

Kaydi,  202 

Kinnicutt,  322 

Kishi,  300 

Ivocher,  10,  11,  12,  14,  64,  73,  87, 

95,  110,  111,  126,  127,  128,  137, 

142,    155,    156,    157,    166,    170, 

175,    179,    188,   281,    311,    312. 

313,  315,  317,  352,  360 
Kohn,    202,    208,    220,    227,    231, 

244,  268,  285 
Kollman,  235 
Konigstein,    237,    243,    255,    256, 

280,  322,  323 
Kursteiner,  212 
Landstrom,  16,  50,  57,  84,  90,  92, 

95,  144,  156,  188,  189,  190 
Lange,  329 


Langhans,  271,  282 

Lanz,  88,  328 

Leighton,  217,  219,  221,  299,  306, 

360 
Leischner,  356 
Lenhart,  28 
Leopold,  351 
Liezenska,  202 
Litty,  222 
Loeb,  346 
Lowenthal,  341 
Lundborg,  249,  251,  252,  337 
Lusena,  288 
Luzzato,  252 

MacCallum,  206,  211,  214,  221, 
223,  241,  246,  248,  250,  255, 
271,  289,  305,  321,  326,  332, 
336,  338,  346,  347,  348,  349 

MacCarty,  30 

Makai,  280 

Manca,  292 

Mant,  341 

Maresch,  249 

Marie,  12,  46,  47,  235 

Marine,  28 

Marinesco,  260,  341 

Maselung,  202 

Maurer,  228 

Mayer,  208,  295,  322,  337,  356 

Mayo,  11,  95,  110,  188,  315,  317 

Mead,  184 

Michelazzi,  341 

Mikulicz,  188,  205,  312 

Moebius,  10,  11,  12,  39,  43,  46,  54, 
57,   86,   91,   95,    178,    179,   186, 
187,  252 
J  Moore,  21 

Morel,  220,  242,  304 

Mossaglia,  332 

Moussu,  221,  247,  284,  285,  329, 
339,  340,  351 

Muller,  243 

Munk,  305 

Murphy,  223 

Murraron,  341 

Musser,  349 

Nagel,  242 

Oddo,  351 
Opie,  322 
Oswald,  196 
Ott,  362 

Paladino,  287 

Parhon,  206,  335,  345,  351 

Parry,  11,  38 

Payr,  170,  171,  353,  354 


REFERENCE  TO  AUTHORITIES. 


375 


Pepere,  226,   244,   256,   268,   279, 

280,  355 
Peterson,  214,  231,  235,  244,  265, 

268 
Peucker,  249 

Pfeiffer,  208,  295,  322,  337,  356 
Pianca,  221 
Pick,  33 
Pineles,  288,   289,   305,   313,   318, 

320 
Pinto,  306 

Pool,  114,  218,  345,  355 
Prenant,  228 
Putnam,  342 

Quadri,  332 
Quest,  346 

Rehn,  11,  188 

Remak,  201 

Rensburg,  341 

Reuss,  351 

Reverdin,  14,  205,  311,  312 

Rey,  341 

Rogers,  86,  186,  215 

Rogowitz,  202,  263 

Rosenberg,  249 

Ross,  242 

Rouxeau,  287 

Rudinger,  333 

Ruppanner,  22 

Russell,  291 

Sabbatani,  346 

Sacerdoti,  226 

Salzer,  125,  171 

Sandstrom,    201,    202,    208,    211, 

213,  231,  234,  243,  281 
Santi,  de,  270 
Sarles,  351 
Schaper,  212,  268 
Schiefferdecker,  252 
Schiff,  171,  281 
Schilder,  246 
Schirmer,  302 
Schleich,  94 
Schlesinger,  249 
Schmauch,  85,  192,  195 
Schmiergeld,  251,  280 
Schmorl,  35,  250,  256,  257,  327 
Schreiber,  213,  228 
Segale,  295,  305 
Serman,  170 
Shaw,  341 
Shephard,  188 
Silvestri,  346 
Simon,  228 
Singer,  70 
Soulie,  228 


Spieler,  341 
Stamm,  163 
Steida,  228 
Stellwag,  12,  57 
Stumme,  320 
Sultan,  171 
Swarts,  219,  299,  360 

Teacher,  35 

Thaler,  329,  330 

Theunveny,  291,  339 

Thiemich,  256,  323 

Thomas,  176 

Thompson,  212,  215,  216,  217,  219, 
221,  239,  245,  253,  255,  257, 
260,  263,  265,  266,  268,  269, 
270,  275,  280,  299,  306,  360 

Thomson,  223 

Tillaux,  11 

Tinker,  53 

Torri,  23 

Tourneux,  208,  228 

Trendelenburg,  98 

Trousseau,  38 

Tuholske,  157,  160 

Urechie,  206,  345 

Vanderlinden,  287,  328 

Van  Ecke,  287 

Vassale,  250,  285,  286,  291,  305, 

328,  331,  337,  340 
Verdun,  208,  228,  230,  269 
Verebely,  208,  213,  217,  231,  237, 

243,    246,    256,    265,    266,   268, 

269,  270,  272,  323 
Verstraeten,  287,  328 
Vincent,  222,  263,  302,  306,  338 
Virchow,  201 
Voegtlin,  206,  346,  347,  348,  349, 

350 

Walbaum,  289,  305,  354 

Walther,  280 

Warfield,  21 

Weichselbaum,  270,  273,  327 

Weiss,  281,  311 

Werelins,  157 

Welsh,  213,  218,  231,  234,  235,  288 

Wiebrecht,  341 

Wilson,  30,  31 

Winternitz,  246 

Wolfler,  20,  202 

Yanasse,  244,  256,  265,  324,  325 

Zanda,  336 
Zanfrognini,  256,  341 
Zielinska,  208 
Zuckerkandl,  212 


INDEX. 


Aberrant  parathyroids,  288 
Abnormalities  of  development,  18 
Abscess,  20 

of  thyroid  gland,  121 

of  thyroid  gland,  how  located,  121 
Accidents  from  anaesthesia,  90 

surgical,  due  to  removal  of  para- 
thyroid glands,  311 
Addison's    disease,    goitre   mistaken 

for,  66 
Adenocarcinoma,  34 
Adenoma,  fcetal,  17,  29 
Administration  of  iodine,  63 

of  ox  parathyroid,  339 

of  thyroid  extract,  63,  78,  197 
Adrenalin,  92 

chloride,  92 
Adult  myxcedema,  25 
Air  embolism,  116 
Albuminuria,  parathyroid  deficiency 

leads  to,  332 
Alopecia,  70 

Amphibians,  embryology  of  parathy- 
roid glands  in,  228 
Amyloidosis,  24 
Anaemia  and  emaciation,  64 

cerebral,  98 
Anaesthesia,  90 

accidents  from,  90 

apparatus  in  rectal,   103 

atropine  and  morphine  to  precede 
ether  in,  95 

danger  of,  in  operation,  91 

local,  91 

in  operation  on  thyroid  gland,  90 

rectal,  100 

remedies  against  dangers  from,  91 

spinal,  105 

thyroidectomy  under  general,  95 
under  local,  94 
Anaesthetic,  choice  of,  92 

ether  only  safe,  in  goitre,  95 

method  of  injecting,  93 
Anasarca,  68 
Anatomical  consideration  of  thyroid 

gland,  130 
Anatomy  of  parathvroid  glands,  209 

in  birds,  225 

in  children,  216 

in  mammals,  220,  225 

of  thyroid  gland,  15 
in  mammals  220,  225 


Angioma,  279 

Animals,  experiments  on,  177 

histology  of  parathyroid  glands  in, 
240 

postoperative  tetany  in,  295 

used  for  experiments,  204 
Antagonism     between     goitre     and 

tetany,  320 
Anterior  jugular  vein,  134 
Antithyroids,  86,  179 

treatment  with  Moebius',  193 
Aplasia,  18 

Apparatus  in  rectal  anaesthesia,  103 
Arsenic,  88 

Arteries,  ligation  of  thyroid,  20 
Artery,  carotid,  148 

external  carotid,  133 

inferior  thyroid,  146 

middle  thyroid,  148 

superior  thyroid,  133 
Athyreosis,  25 
Atrophy,  degenerative  infantile,  257 

of  mammary  glands,  70 

primary  infantile,  21,  257 

sclerotic  infantile,  257 

of  thyroid  gland,  20 
Atropine   and   morphine   to   precede 

ether  in  anaesthesia,  95 
Autotransplantation   of   parathyroid 

glands,  354 
Aves,     embryology    of    parathyroid 
glands  in,  230 

Barium,  347 
Basedowii,  morbus,  12 
Basedow's  disease,  29 
Beaucaine,  92 
Beebe's  serum,  178 
Belladonna,  88 

Birds,  anatomy  of  parathyroid  glands 
in,  225 

parathyroidectomy  fatal  in,  289 
Blood  supply  of  parathvroid  glands, 
217 

of  thyroid  gland,  15 

toxic  substance  in  the,  335 

vessels,  injury  to,  311 
Blushing,  67 
Branchial  cyst,  36,  268 

Cachexia,  14 

strumipriva,  12,  294 


378 


INDEX. 


Cachexia — cont'd. 

thyropriva,  294 
Calcined  goitre,  23 
Calcium  chloride,  diminution  of,  207 

injection  of,  346 

metabolism,    connection    between 
parathyroids  and,  326 

in  tetany,  349 
Carbolic  acid,  injection  of,  79 
Carcinoma,  33,  166 

of  neck,  37 

primary,  33 
Carotid  artery,  148 
Cells,  size  of,  in  parathyroid  glands, 

231 
Cerebral  anaemia,  98 
Changes  in  size  of  thyroid  gland,  40 
Children,    anatomy    of    parathyroid 
glands  in,  216 

rickets  basis  of  tetany  of,  327 

tetany  in,  205,  256,  323 
Chronic  heart  affections,  261 

inflammation,  21 

interstitial  parathyroiditis,  266 

nephritis,  261 

tuberculosis,  261 
Circulatory  disturbances,  18 
Circumscribed  oedema,  67 
Cirrhosis  of  liver,  261,  266 
Cocain,  92 

application  of,  106 
Coley's  serum,  170 
Collapse  of  trachea,  116 

how  to  avoid  bad  results  from,  117 
Colloid,  17,  262 

goitre,  26 

hypersecretion  of,  23 
Color  of  parathyroid  glands,  211 
Complications  of  symptoms,  75 
Conditions  increasing  gravity,  61 

intermittent,  59 

occasionally  present,  65 
Congenital  goitre,  196 

myxcedema,  18 

parathyroid  hypoplasia    in    rachi- 
tis, 327- 
Congestion,  passive,  20,  266 
Conjunctivitis  developed,  309 
Connection      between      parathyroid 
haemorrhage     and     tetanv, 
325 

parathvroids  and  calcium  metabo- 
lism, 326 

parathyroids     and     osteomalacia, 
326 

parathyroids  and  rickets,  326 
Convergence  test  in  diagnosis,  58 
Cortical  irritation,  61 


Cretinism,  endemic,  24 

sporadic,  18,  24 
Cyst,  branchial,  36,  268 

retention,  268 
Cystocarcinoma,  34 
Cysts    and    tumors    of    parathyroid 

glands,  268 
Cytolitic  serum,  186 

Danger  of  anaesthesia  in  operation,  91 

of  operation  on  thyroid  gland,  110 

of  thyroidectomy,  89 
Deficiency,  mental,  55 
Deformities,  how  to  prevent,  154 
Degeneration  of  parathyroid  glands, 
264 

polycystic,  268 

and  infiltration,  23 
Depression,  mental,  61 
Diabetes,  261 
Diagnosis,  convergence  test  in,  58 

errors  in,  54 

electrical  test  in,  54 

of  exophthalmic  goitre,  38 

of  goitre,  36,  38 

of  thyroid  gland,  36 
Diet    following    parathyroidectomy, 

334 
Diffuse  hypertrophy,  26 
Diminution  of  calcium,  207 
Discoloration  of  skin,  65 
Disease,   Addison's,   goitre    mistaken 
for,  66 

Basedow's,  29 

Graves',  12,  29,  178 

Pott's,  35 
Diseased  parathyroids,  hypersuscep- 
tibility  of  nerves  symptoms 
of,  321 

tissues,  nodules  of,  138 
Dissection  of  isthmus,  150 

of  thyroid  gland,  144 
Disturbances,  chronic,  due  to  partial 
loss  of  parathyroids,  305 

circulatory,  18 

insufficiency  of -parathyroids  causes 
convulsive,  313 
of  thyroid  causes  nutritional,  313 

nutritive,    after    parathyroidecto- 
my, 305 
Drainage,  method  of,  153 

provision  for,  153 

value  of,  in  operation,  112 
Dyspnoea,  paroxysmal,  58 

Eclampsia,  256,  327 

of  pregnancy  prevented  by  para- 
thyroids, 321 


INDEX. 


379 


Eclampsia — cont'd. 

thyroid  therapy  relief  in,  331 
Electrical  test  in  diagnosis,  54 

treatment  of  simple  goitre,  81 
Emaciation  and  anaemia,  64 
Embolism,  20 

air,  116 
Embryology  and  histology  of  para- 
thyroid glands,  227 
of  parathyroid  glands,  227 
of  parathyroid  glands  in  amphibi- 
ans, 228 
of  parathyroid  glands  in  aves,  230 
of  parathyroid  glands  in  mamma- 
lia, 230 
of  thymus  gland,  227 
of  thyroid  gland,  227 
Endemic  cretinism,  24 
Endothelioma,  33 
Enlargement  of  lymph  nodes,  71 

of  thymus  gland,  71 
Enucleation  of  thyroid  tumors,  165 
Epilepsy,  205,  250 
Epileptiform  crisis,  311 
Epithelium,  new  formation  of,  23 
Ergotine,  86 

and  hydrobromate  of  quinine,  184 
Errors  in  diagnosis,  54 
Erythema,  67 

Ether,  method  of  administering,  96 
only  safe  anaesthetic  in  goitre,  95 
Trendelenburg  position  in    admin- 
istering, 98 
Etiology  of  hypoparathyroid  glands, 
205 
interest  of  internist  in  hypopara- 
thyroid, 205 
Excitability,  nervous,  52 
Excitation,  psychic,  62 
Exhaustion,  mental,  62 

physical,  62 
Exophthalmic     goitre.     See    Goitre, 

exophthalmic. 
Exophthalmos,  30 
Experiments  on  animals,  177,  204 

opposed  to  tetany,  299 
Exposure,  x-ray,  in  operation  on  thy- 
roid gland,  169 
External  carotid  artery,  133 

parathyroids,  285 
Extirpation  of  thyroid  gland,  14 
Extract,  thyroid,  administration  of, 
63,  78,  197 
in  congenital  goitre,  197 
efficacy  of,  14 
in  fracture,  72 
in  myxcedema,  69 
tetany  benefited  by,  340 


Extract — cont'd. 

tetany  controlled  by  pituitary,  362 
therapeutic  use  of  parathyroid,  337 

Extrathyroideal  tumors,  271 

Fat  in  parathyroid  glands,  260 

Fibrosis,  265 

Fcetal  adenoma,  17,  29 

Fracture,   administration  of   thyroid 

extract  in,  72 
Function  of  parathyroid  glands,  199, 

206 
of  thyroid  gland,  14 

Gall-bladder,  infection  of,  262 
Gastric  tetany,  205,  324 
Gastrointestinal  symptoms,  60 
Gauze,  tamponing  with,  145 
General  appearance  of  patients,  72 
consideration  of  thyroidectomy,  88 
pathology   of  parathyroid   glands, 
260 
Gland,  thyroid.     See  Thyroid  gland. 
Glands,   parathyroid.     See  Parathy- 
roid glands. 
Glandulee  parathyroidse,  202 
Glandules,  inferior  (internal),  210 

superior  (external),  209 
Globus  hystericus,  53 
Goats,  milk  from  thyroidectomized, 
88 
serum  of  thyroidectomized,  86 
Goitre,     antagonism    between,     and 
tetany,   320 
calcified,  23 
colloid,  26 
congenital,  196 
diagnosis  of,  36,  38 
diffuse  hypertrophy  of,  26 
exophthalmic,  29,  39,  74,  205 
diagnosis  of,  36,  38 
complications  of  symptoms  in,  75 
due   to   lesions    of    parathyroid 

glands,  247 
heredity  in,  192 
history  blank  for,  182 
indications  for  operation  on,  123 
prognosis  in,  178 
prognosis    of,    less    hopeful    in 

men,  179 
statistics  of,  188 
symptoms  of,  developed  by  iodide 

of  potassium,  76 
treatment  of,  83,  84 
what  is,  12 
haemorrhage  in,  20 
heart,  12 
heredity  in,  191 


380 


INDEX. 


Goitre — cont'd. 

hypertrophy  of,  25 

minor  list  of  symptoms  of,  45 

minor  symptoms  of,  41 

mistaken  for  Addison's  disease,  66 

nodular  hypertrophy  of,  28 

parenchymatous,  26 

removal,  311 

simple,  72 

heredity  in,  192 

indications  for  operation  in,  119 
electrical  treatment  of,  81 
treatment  of,  77 
Grsefe's  sign,  56 

symptoms,  50 
Graves'  disease,  12,  29,  178 

prognosis  in,  178 
Gravity,  conditions  increasing,  61 
Growths,  histoid,  32 

malignant,  166 

osteoplastic,  33 

Haemorrhage  in  goitre,  20 

in  operation,  110 

in  parathyroid  glands,  265,  324 
Heart  affections,  chronic,  261 

lesions,  266 
Heredity  in  goitre,  191 

in  exophthalmic  goitre,  192 

in  simple  goitre,  192 
Histoid  growths,  32 
Histology,    pathologic,    of    parathy- 
roid glands,  243 

of  infant  parathyroid  glands,  239 

of  parathyroid  glands,  231 

of  parathyroid  glands  in  animals, 
240 
History  blank  for  exophthalmic  goi- 
tre, 182 

of  parathyroid  glands,  199 

of  surgical     diseases     of     thyroid 
gland,  10 
Hydrobromate  of  quinine,  86 

of  quinine  and  ergotine,  184 
Hypersemia,  18 

sexual,  18 
Hyperplasia,  28 

Hypersusceptibility  of.  nerves  symp- 
toms of  diseased   parathy- 
roids, 321 
Hyperthyroidism,  15,  29 

postoperative,  144 
Hypertrophy,  40 

diffuse,  26 

of  goitre,  25 

nodular,  28 

of  parathyroids,  294 
Hypoparathyroid  etiology,  205 


Hypoplasia  of  parathyroids,  327 
Hypothyroidism,  21,  24,  29,  111 
Hysteria,  53 

Idiopathic  tetany,  205,  320 
Incision  in  thyroidectomy,  126 
Indication  for  ligation  of  thyroid  ves- 
sels, 156 
for  operation  in  exophthalmic  goi- 
tre, 123 
in  malignant  growths  of  thyroid 

gland,  124 
in  simple  goitre,  119 
on  thyroid  gland,  119 
Infantile  atrophy,  degenerative,  257 
primary,  21,  257 
sclerotic,  257 
Infantile  myxcedema,  25 
Infant  parathvroid  glands,  histology 

of,  239 
Infarction,  20 
Infection,  114 

of  gall-bladder,  262 
Inferior    (internal)    glandules,  210 

thyroid  artery,  146 
Infiltration  and  degeneration,  23 
Inflammation,  20 

chronic,  21 
Infusion  of  salt  solution  in  tetany, 

337 
Injecting  crushed  thyroid  tissue,  171 

anaesthetic,  method  of,  93 
Injection  of  calcium  chloride,  346 
of  carbolic  acid,  79 
hypodermic,  of  iodine,  87 
intraperitoneal,  of  parathyroid,  338 
intravenous,     of     horse     parathy- 
roid, 339 
intravenous,  of  parathyroid  emul- 
sion, 338 
of  parathyroid  into  jugular  vein, 

338 
position  of  patient  after,  108 
of  sodium  chloride,  345 
of  stovaine  and  strychnine,  107 
subcutaneous,  of  beef  parathyroid 
and  morphine;  338 
of  horse  parathyroid,  339 
of  parathyroid  emulsion,  337 
Injury  to  blood  vessels,  311 

to  parathyroid  glands,  113,  115 
to  recurrent  laryngeal  nerve,  115 
Insane,  patient  may  become,  55 
Insufficiency  of  parathyroids  causes 
convulsive  disturbances,  313 
of  thyroid  causes  nutritional  dis- 
turbances, 313 
Interfollikulaeres  epithel,  202 


INDEX. 


381 


Intermittent  conditions,  59 
Internal  jugular  vein,  133,  148 

parathyroids,  285 
Internist,  interest    of,    in   hypopara- 

thyroid  etiology,  205 
Intraperitoneal  injection  of  parathy- 
roid, 338 
Intrathyrodeal  tumors,  271 
Intravenous  injection  of  horse  para- 
thyroid, 339 
of  parathyroid  emulsion,  338 
Involvement,  metastatic,  280 
Iodide  of   potassium,  symptoms  de- 
veloped by,  76 
Iodine,  administration  of,  63 
hypodermic  injection  of,  87 
internal  and  external  use  of,  87 
ointment,  application  of,  78 
use  of,  may  do  harm,  87 
Irritation,  cortical,  61 
Ischemia  followed  by  tetany,  306 
Isotransplantation     of     parathyroid 

gland  unsuccessful,  357 
Isthmus,  dissection  of,  150 

Jaundice    in  fatty  change  of  para- 
thyroids, 262 

Lactation,  tetany  of,  205,  327 
Lesions,  heart,  266 

of  parathyroid  glands,  exophthal- 
mic goitre  due  to,  247 
Leucocytosis,  64,  122 
Leukaemia,  37 
Life,   parathyroid    glands    necessary 

for,  362 
Ligation  of  superior  poles,  163 

of  thyroid  arteries,  20 

of  thyroid  veins,  160 

of  thyroid  vessels,  155 

of.  thyroid   vessels  as  preliminary 
operation,  156 

of  thyroid  vessels,  various  methods 
of,  157 

of  thyroid  vessels,  when  indicated, 
156 

ultra,  219 

with  catgut,  149 
Lipoma  of  neck,  37 
Liver,  cirrhosis  of,  266 
Luxation  of  thyroid  gland,  142 
Lymph  nodes,  enlargement  of,  71 
Lymphocytosis,  64 
Lymphona,  279 
Lymphosarcoma,  37 
Lymph  spaces,  16 

Magnesium,  347 


Malignant  growths  of  thyroid  gland, 
166 

indication  for  operation  in,  124 
Mammalia,  embryology  of  parathy- 
roid glands  in,  230 
Mammals,   anatomy  of  parathyroid 
glands  in,  220 

anatomy  of  thyroid  gland  in,  225 
Mammary  glands,  atrophy  of,  70 
Meat  diet  may  produce  tetany,  335 
Medication,  specific,  85 
Medulla  oblongata,  12 
Mental  deficiency,  55 

depression,  61 

exhaustion,  62 
Metabolic  toxin,  207 
Metabolism  origin  of  tetany  poison, 

326 
Metastasis,  33 

Metastatic  involvement,  280 
Milk,  natural,  feeding  after  thyropa- 

rathyroidectomy,  335 
Moebius'    antithyroidin,     treatment 
with,  193 

serum,  178,  186 

sign,  57 

symptoms,  50 
Morbus  Basedowii,  12 
Morphine   and   atropine   to   precede 

ether  in  anaesthesia,  95 
Muscles,  omohyoid,  136 

platysma  myoides,  132 

sternocleido,  137 

sternocleido-mastoid,  132 

sternohyoid,  136 

sternothyroid,  136 
Muscular  weakness,  49 
Myocarditis,  42 
Myoma,  279 
Myxcedema,  12,  68,  249 

adult,  25 

congenital,  18 

fruste,  25 

infantile,  25 

operative,  25 

Natural  milk  feeding  after  thyro- 

parathyroidectomy,  335 
Necrosis,  pressure,  152 
Nephritis,  chronic,  261 

toxic  glomerulo,  265 

parenchymatous,  265 
Nerve,  phrenic,  133 

pneumogastric,  148 

recurrent  laryngeal,  133,  147 
injury  to,  115 

supply  of  parathyroid  glands,  226 

vagus,  133 


382 


INDEX. 


Nerves,  hypersusceptibility  of,  symp- 
toms of  diseased   parathy- 
roids, 321 
Nervous  excitability,  52 
Neurasthenia,  53 
Nodular  hypertrophy,  28 
Nodules,  accessory  thyroid,  18 
of  diseased  tissues,  138 
pressing  upon  trachea,  150 
Nomenclature  of  parathvroid  glands, 

208 
Non-malignant  diseases,  82 
Non-surgical    treatment    of    thyroid 

gland,  77 
Novocain,  92 

Nucleoproteid  of  parathyroid  gland, 
342 
clinical  value  of,  345 
how  to  administer,  343 
how  to  prepare,  343 
Nutritive  disturbances  after  parathy- 
roidectomy, 305 

Oedema,  circumscribed,  67 
Operation,  anaesthesia  in,  on  thvroid 
gland,  90 
danger  of  anaesthesia  in,  91 
of,  on  thyroid  gland,  110 
haemorrhage  in,  110 
indication    for,     in    exophthalmic 
goitre,  123 
for,    in    malignant    growths    of 

thyroid  gland,  124 
for,  in  simple  goitre,  119 
for,  on  thyroid  gland,  124 
parathyroids  to  be  spared  in  thy- 
roid, 316 
shock  from,  110 
Stamm-Jacobson,  163 
value  of  drainage  in,  112 
x-ray    exposure    in,     on    thyroid 
gland,  169 
Operations,  other,  on  thyroid  gland, 

163 
Operative  myxcedema,  25 
Osteomalacia,  72,  205,  257 

connection   between   parathyroids 
and,  326 
Osteoplastic  growths,  33 
Ostitis  deformans,  274 
Ox   parathyroid,   administration   of, 
339 


Paraparesis,  50 
Paralysis  agitans,  205,  251 
Parathyroid,  administration    of    ox, 
339 


Parathyroid — cont'd. 

beef,  and  morphine,  subcutaneous 
injection  of,  338 

deficiency    leads    to    albuminuria, 
332 

emulsion,     intravenous     injection 
of,  338 

emulsion,  subcutaneous     injection 
of,  337 

etiology,  205 

extract,  tetany  benefited  by,  340 
therapeutic  use  of,  337 

haemorrhage,  connection  between, 
and  tetany,  325 

injection  of,  into  jugular  vein,  338 

insufficiency,    tetany    rests    upon, 
333 

intraperitoneal  injection  of,  338 

intravenous  injection  of  horse,  339 

subcutaneous   injection    of   horse, 
339 

subcutaneous    transplantation    of, 
337 

tetany,    toxin  hypothesis   of,    335 

theory  of  tetany,  323 

therapy,  334 
Parathyroids,  aberrant,  288 

chronic  disturbances  due   to  par- 
tial loss  of,  305 

connection  between,    and   calcium 
metabolism,  326 
between,  and  osteomalacia,  326 
between,  and  rickets,  326 

eclampsia  of  pregnancy  prevented 
by,  321 

external,  283 

haemorrhage  in,  324 

hypersusceptibility  of  nerves  symp- 
toms of  diseased,  321 

hypertrophy  of,  294 

hypoplasia  of,  327 

insufficiency  of,  causes  convulsive 
disturbances,  313 

internal,  285 

to    be    spared    in    thyroid    opera- 
tions, 316 
Parathyroid  gland,  clinical  value  of 
nucleoproteid  of,  343 

how   to   administer   nucleoproteid 
of,  343 

how  to  prepare  nucleoproteid  of. 
343 

isotransplantation    of,    unsuccess- 
ful, 357 

nucleoproteid  of,  342 

transplantation    of,    into    human 
being,  359 

transplantation  of,  into  tibia,  360 


INDEX. 


383 


Parathyroid  glands,  199 
anatomy  of,  209 
in  birds,  225 
blood  supply,  217 
in  children,  216 
color,  211 

inferior  (internal)  glandules,  210 
location,  209 
in  mammals,  220,  225 
nerve  supply,  226 
shape,  211 
size,  210 
superior     (external)     glandules, 

209 
variations  in  numbers,  212 
ultra  ligation,  219 
weight,  211 
cysts  and  tumors  of,  268 
angioma,  279 
branchial  cysts,  268 
branchial  polycystoma,  268 
lymphona,  279 
metastatic  involvement,  280 
myoma,  279 

polycystic  degeneration,  268 
retention  cysts,  268 
tumors   of    parathyroid    glands, 
270 
extrathyroideal,  271 
intrathyroideal,  271 
ostitis  deformans,  274 
embryology  and  histology  of,  227 
embryology,  227 
amphibians,  228 
aves,  230  . 
mammalia,  230 
thymus  gland,  227 
thyroid  gland,  227 
histology,  231 
in  animals,  240 
of  infant  parathyroid,  239 
secretion  of  parathyroid 

glands,  241 
tvpe    1,    comparatively   small 

cells,  231 
tvpe   2,    comparatively    large 
cells,  232 
history  of,  199 

animals    used    for    Experiments, 

204 
function,  199,  206 
glandulae  parathyroidse,  202 
hypoparathyroid  etiology,  205 
children's  tetany,  205 
gastric  tetany,  205 
epilepsy,  205 
exophthalmic  goitre,  205 
idiopathic  tetany,  205 


Parathyroid  glands — cont'd, 
osteomalacia,  205 
paralysis  agitans,  205 
rickets,  205 

tetany  of  lactation,  205 
of  pregnancy,  205 
interfollikulaeres  epithel,  202 
independent  vital  organs,  206 
nomenclature,  208 
parathyroid  therapy,  205 
restes  embryonnaires,  202 
tetany  symptoms,  207 

diminution  of  calcium,  207 
metabolic  toxin,  207 
parathyroid  therapy,  334 
barium,  347 
calcium  in  tetany,  349 
diet,  334 
infusion     of     salt     solution     in 

tetany,  337 
injection  of  calcium  chloride,  346 
of    parathvroid    into    jugular 

vein,  338 
of  sodium  chloride,  345 
intraperitoneal  injection  of  para- 
thyroid, 338 
intravenous    injection    of    horse 

parathyroid,  339 
intravenous   injection    of    para- 
thyroid emulsion,  338 
magnesiuni,  347 
meat  diet  mav  produce  tetany, 

335 
natural  milk  feeding  after  thyro- 

parathyroidectomy,  335 
nucleoproteid      of     parathyroid 
gland,  342 
clinical  value  of,  345 
how  best  administered,  343 
how  prepared,  342 
ox  parathyroid  administered  to 

human  beings,  339 
parathyroid     glands     necessary 
for  life,  362 
vital  organs,  362 
strontium,  347 

subcutaneous   injection   of   beef 
parathyroid  and  morphine, 
338 
of  horse  parathyroid,  339 
of  parathyroid  emulsion,  337 
subcutaneous  transplantation  of 

parathyroid,  337 
tetany  a  symptom,  362 

benefited   by  parathyroid   ex- 
tract, 340 
benefited  bv  thyroid   extract, 
340 


384 


INDEX. 


Parathyroid  glands — cont'd. 

tetany  controlled  after  parathy- 
roidectomy, 362 
therapeutic  use  of  parathyroid 

gland,  337 
thyroparathyroidectomy,  348 
toxic  substance  in  the  blood,  335 
toxin  hypothesis  of  parathyroid 

tetany,  335 
transfusion  in  tetany,  336 
transplantation    of    parathyroid 
glands,  351 
autotransplantation,  354 
into  human  being,  359 
into  shaft  of  tibia,  360 
isotransplantation   unsuccess- 
ful, 357 
parathyroids      grafted       into 
spleen,  355 
trisodic  citrate  solutions,  346 
pathologic  histology  of,  243 
colloid,  262 
degenerations,  264 
eclampsia,  256 
epilepsy,  250 
exophthalmic  goitre,  247 
general  pathology,  260 
fat,  260 

chronic  heart  affections,  261 
chronic  nephritis,  261 
chronic  tuberculosis,  261 
cirrhosis  of  liver,  261 
diabetes,  261 

infection  of  gall-bladder,  262 
jaundice,  262 
pyelonephrosis,  261 
fibrosis,  265 

chronic  interstitial  parathy- 

roiditis,  266 
cirrhosis  of  liver,  266 
heart  lesions,  266 
passive  congestion,  266 
haemorrhage,  265 

toxic  glomerulo-nephritis,  265 
acute  parenchymatous  nephri- 
tis, 265 
morphological  observations,  243 
myxcedema,  249 
osteomalacia,  257 
paralysis  agitans,  251 
pellagra,  260 

primary   infantile   atrophy,    257 
degenerative,  257 
sclerotic,  257 
rachitis,  256 
tetanus,  255 
tetany,  255 

of  children,  256 


Parathyroid  glands — cont'd. 

tuberculosis    of    parathyroid 
glands,   246 
relation  of,  to  medical  tetany,  318 
antagonism  between  goitre  and 

tetany,  320 
children's  tetany,  323 
congenital     parathyroid     hypo- 
plasia in  rachitis,  327       * 
connection  between  parathyroid 
haemorrhage     and     tetany, 
325 
between  parathyroids  and  cal- 
cium metabolism,  326 
between  parathyroids  and  os- 
teomalacia, 326 
between  parathyroids  and  rick- 
ets, 326 
eclampsia,  327 

of  pregnancy  prevented  by  pa- 
rathyroids, 321 
gastric  tetany,  321 
haemorrhage  in  parathyroids,  324 
hypersusceptibility     of     nerves 
symptoms  of  diseased  para- 
thyroids, 321 
hypoplasia  of  parathyroids,  327 
idiopathic  tetany,  320 
metabolism     origin     of     tetany 

poison,  326 
parathyroid  deficiency  leads  to 

albuminuria,  332 
parathyroid    theory    of    tetany, 

323 
rickets  basis   of  tetanv   of  chil- 
dren, 327 
tetany  of  lactation,  327 
of  pregnancy,  327 
rests  upon  parathyroid  insuf- 
ficiency, 333 
thyroid  therapy  relief  in  eclamp- 
sia, 331 
uniform    tetany    symptoms    in 
man  and  animals,  320 
relation  of,  to  postoperative  tetany, 
281 
aberrant  parathyroids,  288 
cachexia  strumipriva,  294 

thyropriva,  294 
chronic  disturbances  due  to  par- 
tial loss  of  parathyroids,  305 
nutritive  disturbances,  305 
conjunctivitis  developed,  309 
experiments  opposed  to  tetany, 

299 
external  parathyroids,  285 
hypertrophy,  294 
internal  parathyroids,  285 


INDEX. 


185 


Parathyroid  glands — cont'd. 

ischemia  followed  by  tetany,  306 
parathyroidectomy  fatal  in  birds, 

289 
postoperative  tetany  in  animals, 

295 
tetany  due  to  loss  of  parathy- 
roid glands,  312 
experiments  on  animals,  2S3 
surgical  accidents  due  to  removal 
of,  311 
epileptiform  crisis,  311 
goitre  removal,  311 
how  to  escape  tetany,  311 
injury  to  blood  vessels,  311 
insufficiency      of      parathyroids 
causes    convulsive    disturb- 
ances, 313 
of  thyroid   causes  nutritional 
disturbances,  313 
parathyroids    to    be    spared    in 

thyroid  operations,  316 
postoperative    tetanv    less    fre- 
quent, 316 
subcapsular  procedure,  316 
tabulated    cases    of   tetany   fol- 
lowing    partial     thyroidec- 
tomy, 314 
tetania  parathyropriva,  315 
tetany  due  to  loss  of  parathy- 
roid glands,  312 
tetany  not  due  to  loss  of  thvroid 
gland,  312 
Parathyroidectomy,    diet    following 
334 
fatal  in  birds,  289 
nutritive  disturbances  after,  305 
tetany  controlled  after,  362 
Parathyroiditis,    chronic  interstitial, 

266 
Parathyroid  therapy,  334 
Parenchymatous  goitre,  26 

nephritis,  265 
Paroxysmal  dyspnoea,  58 
Passive  congestion,  20,  266 
Pathologic  histology  of  parathyroid 

glands,  243 
Pathology,    general,    of    parathyroid 
glands,  260 
of  thyroid  gland,  14 
Patient  may  become  insane,  55 
Patients,  general  appearance  of,  72 
Pellagra,  260 
Perithelium,  33 
Phrenic  nerve,  133 
Physical  exhaustion,  62 
Pituitary  extract,   tetany  controlled 
by,  362 


Pneumogastric  nerve,  145 
Poisoning,  symptoms  of  thyroid,  44 
Poles,  ligation  of  superior,  163 
Polycystic  degeneration,  268 
Position  of  patient  after  injection,  108 
Postoperative    hyperthyroidism,  144 
tetany  in  animals,  295 
tetany  less  frequent,  316 

relation   of   parathyroid   glands 
to,  281 
Pott's  disease,  35 
Primary  carcinoma,  33 

sarcoma,  33 
Pregnancy,  eclampsia  of,   prevented 
by  parathyroids,  321 
tetany  of,  205,  327 
Procedure,  subcapsular,  316 
Prognosis  in  exophthalmic  goitre,  178 
of  exophthalmic  goitre  less  hopeful 

in  men,  179 
in  Graves'  disease,  178 
Pseudoleukemia,  37 
Psychic  excitation,  62 
Pulse  beat  varies,  40 
Pyelonephrosis,  261 

Quinine,  hydrobromate  of,  86 
Quinine,  hydrobromate  of,  and  ergo- 
tine,  184 

Rachitis,  256 

Rachitis,  congenital  parathyroid  hy- 
poplasia in,  327 
Recognition  of  thyroid  gland,  132 
Rectal  anaesthesia,  100 

advantages  of,  100 

apparatus  in,  103 

method  of  application  of,  101 

technic  of,  102 
Recurrent  laryngeal  nerve,  133 
Relation    of    parathyroid    glands    to 
medical  tetany,  318 

to  postoperative  tetany,  281 
Remedies  against  clangers  from  anaes- 
thesia, 91 
Removal  of  goitre,  311 

of  portion  of  thyroid  gland,  69 
Restes  embryonnaires,  202 
Retention  cysts,  268 
Rickets,  205 

basis  of  tetany  of  children,  327 

connection    between    parathyroids 
and,  326 

Sarcocarcinoma,  35 
Sarcoma,  33,  35,  166 

primary,  33 
Scleroderma,,  70 


386 


INDEX. 


Secretion  of  parathyroid  glands,  241 
Septicaemia,  20 
Serum,  Beebe's,  178 

Coley's,  170 

cytolitic,  186 

Moebius',  178,  186 

of  thyroidectomized  goats,  86 
Sexual  hypersemia,  18 
Shape  of  parathyroid  glands,  211 
Shock  from  operation,  110 
Sign,  Graefe's,  56 

Moebius',  57 

Stellwag's,  57 
Simple   goitre.     See    Goitre,    simple.. 
Size  of  parathyroid  glands,  210,  231 

of  thyroid  gland,  130 

of  thyroid  gland  changes,  40 
Skin,  discoloration  of,  65 
Sodium  chloride,  injection  of,  345 

phosphate,  87 
Solutions,  trisodic  citrate,  346 
Specific  medication,  85 
Spinal  anaesthesia,  105 
Spleen,  parathyroid  glands    grafted 

into,  355 
Sporadic  cretinism,  18,  24 
Stamm-Jacobson  operation,  163 
Statistics  of  exophthalmic  goitre,  188 
Stellwag's  sign,  57 

symptoms,  50 
Stovaine  and  strvchnine,  application 
of,  106  " 

injection  of,  107 

preparation  of,  106 
Strontium,  347 
Strophantus,  88 
Strumitis,  167 
Subcapsular  procedure,  316 
Subcutaneous  injection  of  beef  para- 
thyroid and  morphine,  338 

injection  of  horse  parathyroid,  339 

injection  of  parathyroid  emulsion, 
337 

transplantation  of  parathyroid,  337 
Surgical  accidents  due  to  removal  of 
parathyroid  glands,  311 

consideration  of  thyroid  gland,  9 

diseases,  history  of,  10 
Superior  (exterior)  glandules,  209 

poles,  ligation  of,  163 

thyroid  artery,  133 

thyroid  vein,  134 
Sutures,  catgut,  149 

horsehair,  154 

silk,  154 

skin,  154 

subcuticular,  154 

when  to  be  cut,  154 


Symptom,  tetany  a,  362 
Symptoms,  complications  of,  75 

developed  by  iodide  of  potassium, 
76 

gastrointestinal,  60 

Graefe's,  50 

list  of  minor,  of  goitre,  45 

minor,  of  goitre,  41 

Moebius',  50 

Stellwag's,  50 

thyroid  poisoning,  44 

tetany,  207 

uniform  tetany,   in  man  and   ani- 
mals, 320 
Syncope,  122 

Syphilis,  tertiary,  of  thyroid  gland, 
23 

of  thyroid  gland,  22 

Tabulated  cases  of  tetany  follow- 
ing partial   thyroidectomy, 
314 
Tachycardia,  38,  44 
Tamponing  with  gauze,  145 
Technic  of  thyroidectomy,  126 

of  transplantation  of  thvroid  gland, 
173 
Test,  convergence,  in  diagnosis,  58 

electrical,  in  diagnosis,  54 
Tetania  parathyropriva,  315 
Tetanus,  255 
Tetany,  49,  255 

antagonism    between,    and  goitre, 

320 
benefited  by  thyroid  extract,  340 
calcium  in,  349 
of  children,  205,  256,  323 
of  children,  rickets  basis  of,  327 
connection    between    parathyroid 

haemorrhage  and,  325 
controlled      after      parathyroidec- 
tomy, 362 
controlled  by  pituitary  extract,  362 
due  to  loss  of  parathyroid  glands, 

312 
experiments  opposed  to,  299 
gastric,  205,  321 
how  to  escape,  311 
idiopathic,  205,  320 
infusion  of  salt  solution  in,  337 
ischemia  followed  by,  306 
of  lactation,  205,  327 
meat  diet  may  produce,  335 
medical,    relation    of    parathyroid 

glands  to,  318 
not  due  to  loss  of  thyroid  gland, 

312 
parathyroid  theory  of,  323 


INDEX. 


387 


Tetany — cont'd. 

poison,  metabolism  origin  of,  326 
postoperative,  in  animals,  295 
less  frequent,  316 
relation   of    parathyroid    glands 
to,  281 
of  pregnancy,  205,  327 
rests     upon     parathyroid     insuffi- 
ciency, 333 
a  symptom,  362 
symptoms,  207 
symptoms   uniform    in    man    and 

animals,  320 
tabulated  cases  of,  following  par- 
tial thyroidectomy,  314 
toxin   hypothesis   of   parathyroid, 

335 
transfusion  in,  336 
Therapeutic  use  of  parathyroid  ex- 
tract, 337 
Therapy,  parathyroid,  334 

thyroid,  relief  in  eclampsia,  331 
Thymus  gland,  88 
embryology  of,  227 
enlargement  of,  71 
Thyroaplasia,  24 
Thyroid  arteries,  ligation  of,  20 
artery,  middle,  148 
extract,  administration  of,  63,  78, 
197 
in  congenital  goitre,  197 
efficacy  of,  14 
in  fracture,  72 
in  myxcedema,  69 
tetany  benefited  by,  340 
Thyroid  gland,  9 

anaesthesia  in  operation  on,  90 
accidents,  90 

atropine  and  morphine  to  pre- 
cede ether,  95 
'  choice  of  anaesthetic,  92 
adrenalin,  92 
adrenalin  chloride,  92 
beaucaine,  92 
cocain,  92 
novocain,  92 
danger  of,  in  operation,  91 
ether    only    safe    anaesthetic    in 
goitre,  95 
method  of  administering,  96 
cerebral  anaemia,  98 
Trendelenburg  position,  98 
local,  91 
method  of  injecting  anaesthetic, 

93 
morphine,  95 
rectal,  100 

advantages  of,  100 


Thyroid  gland — cont'd, 
apparatus  in,  103 
method  of  application,  101 
technic  of,  102 
remedies  against  dangers  from, 

91 
spinal,  105 

application  of  cocain,  106 
of  stovaine  and  strychnine, 
106 
preparation    of  stovaine  and 
strychnine   solution,    106 
the  injection,  107 
position  of  patient  after  in- 
jection, 108 
upper  dorsal  puncture,  107 
thyroidectomy  under  local,  94 
under  general,  95 
dangers  of  operation  on,  110 
air  embolism,  116 
collapse  of  trachea,  116 

how  to  avoid  bad  results,  117 
haemorrhage,  110 
hyperthyroidism,  111 
infection,  114 
injury    to    parathyroid    glands, 

113,  115 
injury    to    recurrent    laryngeal 

nerve,  115 
shock,  110 

value  of  drainage,  112 
diagnosis  of,  36 
branchial  cyst,  36 
carcinoma  of  neck,  37 
changes  in  size,  40 
exophthalmic  goitre,  38 
hypertrophy,  40 
leukaemia,  37 
lipoma  of  neck,  37 
lymphosarcoma,  37 
•    minor  symptoms,  41 
myocarditis,  42 
tachycardia,  44 
thyroid  poisoning,  44 
minor  symptoms,  list  of,  45 
alopecia,  70 
atrophy  of  mammarv  glands, 

70 
blushing,  67 

circumscribed  oedema,  67 
differentiated      from      ana- 
sarca, 68 
complications,  75 
conditions  increasing  gravity, 
61 
administration  of  idoine,  63 
administration    of    thyroid 
extract,  63 


388 


INDEX. 


Thyroid  gland — cont'd. 

mental  exhaustion,  62 

physical  exhaustion,  62 

psychic  excitation,  62 
conditions    occasionally   pres- 
ent, 65 
discoloration  of  the  skin,  65 

mistaken  for  Addison's  dis- 
ease, 66 
emaciation  and  anaemia,  64 

decreased  leucocytosis,  64 

increased  lymphocytosis,  64 
enlargement  of  lymph  nodes, 

71 
enlargement  of  thymus  gland, 

71 
erythema,  67 

general    appearance     of     pa- 
tients, 72 

exophthalmic  goitre,  74 

simple  goitre,  72 
Graefe's  sign,  56 
intermittent  conditions,  59 

cortical  irritation,  61 

gastrointestinal   symptoms, 
60 

mental  depression,  61 
mental  deficiency,  55 

insane  person,  55 

patient  mav  become  insane, 
55 
Moebius'  sign,  57 
muscular  weakness,  49 

Graefe's  symptoms,  50 

Moebius'  symptoms,  50 

paraparesis,  50 

Stellwag's  symptoms,  50 
myxcedema,  68 
nervous  excitability,  52 

convergence  test,  58 

electrical  test,  54 

errors  in  diagnosis,  54 

globus  hystericus,  53 

hysteria,  53 

neurasthenia,  53 
osteomalacia,  72 
paroxysmal     dyspnoea     (Bry- 

son's  symptoms),  58 
removal  of  portion  of  thyroid 

gland,  69 
scleroderma,  70 
Stellwag's  sign,  57 
tremor,  46 

tetany,  49 
urticaria,  67 
vertigo,  55 
pseudoleukemia,  37 
pulse  beat  varies,  40 


Thyroid  gland — cont'd, 
tachycardia,  38 
heredity  in  goitre,  191 

administration    of    thyroid    ex- 
tract, 197 
congenital  goitre,  196 
exophthalmic  goitre,  192 
simple  goitre,  192 
treatment  with  Moebius'antithy- 
roidin,  193 
indications  for  operation  on,  119 
abscess,  121 

exophthalmic  goitre,  123    . 
malignant  growths,  124 
simple  goitre,  119 
non-surgical  treatment  of,  77 
iodine,  use  of,  87 
arsenic,  88 
belladonna,  88 
hypodermic  injection  of,  87 
internal  and  external  use  of, 

87 
milk    from    thyroidectomized 

goats,  88 
strophantus,  88 
thymus  gland,  88 
use  of,  may  do  harm,  87 
treatment  of  exophthalmic  goi- 
tre, 83 
antithyroidin,  86 
ergotine,  86 

hydrobromate  of  quinine,   86 
serum     of     thyroidectomized 

goats,  86 
sodium  phosphate,  87 
specific  indication,  85 
treatment  of  simple  goitre,  77 
electrical  treatment,  81 
injection  of  carbolic  acid,  79 
iodine  ointment  applied,  78 
non-malignant  diseases,   82 
thvroid  extract  administered, 
78 
other  operations  on,  163 

enucleation  of  thvroid     tumors, 
165 
operation,  165 
ligation  of  superior  poles,  163 
malignant    growths    of    thyroid 
gland,  166 
carcinoma,  166 
Coley's  serum,  170 
sarcoma,  166 
strumitis,  167 

sub-acute  inflammation,  167 
thyroiditis,  167 
x-ray  exposures,  169 
Stamm-Jacobson  operation,  16 


INDEX. 


389 


Thyroid  gland — cont'd. 

transplantation  of  thyroid  gland, 
125, 170 

experiments  in  animals,  177 

injecting  crushed  thyroid  tis- 
sue, 171 

selection  of  material,  175 

technic  of  transplantation, 173 
pathology  of,  14 

abnormalities    of    development, 
18 

accessory  thyroid  nodules,  18 

aplasia,  18 

congenital  myxcedema,  18 

hyperthyroidism,  15,  29 

sporadic  cretinism,  18 
anatomy,  15 

colloid,  17 

fcetal  adenoma,  17 

gross  blood  supply,  15 

lymph  spaces,  16 
cachexia,  14 
carcinoma,  33 

adenocarcinoma,  34 

cystocarcinoma,  34 

Pott's  disease,  35 

primary,  33 

sarcocarcinoma,  35 

sarcoma,  35 
circulatory  disturbances,  18 

atrophy,  20 

embolism,  20 

goitre,  19 

haemorrhage,  20 

hyperaemia,  18 
sexual,  18 
infarction,  20 

ligation  of  thyroid  arteries,  20 

passive  congestion,  20 
degeneration  and  infiltration,  23 

amyloidosis,  24 

calcified  goitre,  23 

hypersecretion  of  colloid,  23 

new  formation  of  epithelium, 
23 
extirpation,  14 
function,  14 
hypothyroidism,  15,  24,  29,  111 

adult  myxcedema,  25 

athyreosis,  25 

Basedow's  disease,  29 

endemic  cretinism,  24 

exophthalmic  goitre,  29 

exophthalmos,  30 

Graves'  disease,  29 

infantile  myxcedema,  25 

myxcedeme  fruste,  25 

operative  myxcedema,  25 


Thyroid  gland — cont'd. 

sporadic  cretinism,  24 
thyroaplasia,  24 
hypertrophv  (goitre),   25 
diffuse,  26 
colloid,  26 
hyperplasia,  28 
parenchymatous,  26 
nodular,  28 

fcetal  adenoma,  29 
inflammation,  20 
abscess,  20 
septicaemia,  20 
thyroiditis,  20 
inflammation,  chronic,  21 
hypothyroidism,  21 
primary  infantile  atrophy,  21 
sarcoma,  33 

endothelioma,  33 
metastasis,  33 
osteoplastic  growths,  33 
perithelium,  33 
primary,  33 
syphilis,  22 

tertiary,  23 
thyroid  extracts,  efficacy  of,  14 
tuberculosis,  21 
tumors,  32 

histoid  growths,  32 
prognosis  in  exophthalmic  goitre, 
178 
antithyroidin,  179 
Beebe's  serum,  178 
cytolitic  serum,  186 
Graves'  disease,  178 
history  blank,  182 
hydrobromate    of    quinine    and 

ergotine,  184 
less    hopeful    in    men    than  in 

women,  179 
Moebius'  serum,  186 
statistics,  188 
surgical  consideration  of,  9 

history  of  surgical  diseases,  10 
cachexia  strumipriva,  12 
exophthalmic  goitre,  what  is,  12 
goitre  heart,  12 
Graves'  disease,  12 
medulla  oblongata,  12 
morbus  Basedow,  12 
myxcedema,  12 
thyroidectomy,  10 
thyroidectomy,  126 

anatomical  consideration,  130 
anterior  jugular  vein,  134 
carotid  artery,  148 
deformities,  how   to   prevent, 
154 


390 


INDEX. 


Thyroid  gland — cont'd. 

dissection  of  isthmus,  150 
dissection    of    thvroid    gland, 

144 
drainage,  provision  for,  153 

method  of,  153 
external  carotid  artery,  133 
how  thyroid  gland  recognized, 

132 
inferior  thyroid  artery,  146 
internal  jugular  vein,  133,  148 
ligation  of  thyroid  veins,  160 

operation,  160 
ligation  of  thyroid  vessels,  155 
as    preliminary     operation, 

156 
various  methods  of,  157 
when  indicated,  156 
ligation  with  catgut,  149 
luxation  of  thyroid  gland,  142 
middle  thyroid  artery,  148 
muscles,  136 
omohyoid,  136 
platysma  myoides,  132 
sternocleido,  137 
sternocleido-mastoid,  132 
sternohyoid,  136 
sternothyroid,  136 
necrosis,  pressure,  152 
nodules  of  diseased  tissues,  138 
nodules  pressing  upon  trachea, 

150 
phrenic  nerve,  133 
pneumogastric  nerve,  145 
postoperative     hyperthyroid- 
ism, 144 
recurrent  laryngeal  nerve,  133 
superior  thyroid  artery,  133 
superior  thyroid  vein,  134 
sutures,  154 
catgut,  149 
horsehair,  154 
silk,  154 
skin,  154 
subcuticular,  154 
when  to  be  cut,  154 
tamponing  with  gauze,  145 
tracheotomy,  when  to  be  per- 
formed, 151 
vagus  nerve,  133 
incision,  126 
technic,  126 
Thyroidectomized  goats,  milk  from, 

88 
Thyroidectomy,  10,  126 
dangers  of,  89 
general  consideration  of,  88 
incision  in,  126 


Thyroidectomy — cont'd. 

tabulated  cases  of  tetany  follow- 
ing partial,  314 
technic  of,  126 
under  local  anaesthesia,  94 
under  general  anaesthesia,  95 
Thyroiditis,  20,  167 
Thyroparathyroidectomy,  348 

natural  milk  feeding  after,  335 
Toxic  glomerulo-nephritis,  265 
substance  in  the  blood,  335 
Toxin     hypothesis     of     parathyroid 
tetany,  335 
metabolic,  207 
Trachea,  collapse  of,  116 

how  to  avoid  bad  results  from  col- 
lapse of,  117 
nodules  pressing  upon,  150 
Tracheotomy,  when  to  be  performed, 

151 
Transfusion  in  tetany,  336 
Transplantation  of  parathvroid  gland, 
351 
of  parathyroid  gland  into  human 

being,  359 
of  parathyroid  gland  into  tibia,  360 
parathyroid  gland  restored  by,  113 
subcutaneous,    of    parathyroid 
gland,  337 
.  of  thyroid  gland,  70,  125,  170 
of  thyroid  gland,   selection   of  ma- 
terial for,  175 
of  thyroid  gland,  technic  of,  173 
Treatment    of    exophthalmic    goitre, 
83,  84 
non-surgical,  of  exophthalmic  goi- 
tre, 77 
of  simple  goitre,  77 

with  electricity,  81 
with  Moebius'  antithyroidin,  193 
Tremor,  46 

Trendelenburg   position   in   adminis- 
tering ether,  98 
Trisodic  citrate  solutions,  346 
Tuberculosis,  chronic,  261 
of  parathyroid  glands,  246 
of  thyroid  gland,  21 
Tumors,  enucleation  of  thyroid,  165 
extrathyroideal,  271 
intrathyroideal,  271 
of  parathyroid  glands,  270 
of  thyroid  gland,  32 

Ultra  ligation,  219 

Uniform   tetany   symptoms   in   man 

and  animals,  320 
Urticaria,  67 

Vagus  nerve,  133 


INDEX. 


391 


Variations  in  number  of  parathyroid 

glands,  212 
Vein,  anterior  jugular,  134 

internal  jugular,  148 

jugular,    injection    of    parathyroid 
into,  338 

ligation  of  thyroid,  160 

superior  thyroid,  134 
Vertigo,  55 
Vessels,  ligation  of  thyroid,  155 


Vital  organs,  parathyroid  glands  in- 
dependent, 206,  362 

Weakness,  muscular,  49 
Weight  of  parathyroid  glands,  212 
of  thyroid  gland,  130 

X-ray  exposure  in  operation  on  thy- 
roid gland,  169 


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